- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,467.37 / $6,760.83
| Facility | | $1,000.00 | $3,467.37 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $933.25 / $1,778.28
| Professional | | $831.76 | $933.25 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,096.48 / $1,258.93
| Professional | | $870.96 | $1,096.48 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $1,862.09 / $10,232.93
| Facility | | $954.99 | $1,862.09 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,047.13 / $6,760.83
| Professional | | $758.58 | $1,047.13 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $5,754.40 / $10,715.19
| Facility | | $1,621.81 | $5,754.40 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $933.25 / $1,258.93
| Professional | | $741.31 | $933.25 | $1,258.93 |