- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,918.31 / $10,964.78
| Facility | | $4,466.84 | $6,918.31 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,174.90 / $3,630.78
| Professional | | $1,000.00 | $1,174.90 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,737.80 / $4,365.16
| Professional | | $1,000.00 | $1,737.80 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,737.80 / $2,137.96
| Professional | | $1,288.25 | $1,737.80 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,309.57 / $10,000.00
| Facility | | $3,981.07 | $6,309.57 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,348.96 / $4,466.84
| Professional | | $1,000.00 | $1,348.96 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,606.93 / $10,964.78
| Facility | | $2,951.21 | $6,606.93 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,380.38 / $2,570.40
| Professional | | $977.24 | $1,380.38 | $2,570.40 |