- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,818.38 / $11,481.54
| Facility | | $2,398.83 | $2,818.38 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,000.00 / $1,380.38
| Professional | | $812.83 | $1,000.00 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,677.35 / $6,309.57
| Facility | | $3,467.37 | $4,677.35 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,698.24 / $2,630.27
| Professional | | $851.14 | $1,698.24 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,698.24 / $2,884.03
| Professional | | $1,230.27 | $1,698.24 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $10,000.00
| Facility | | $10,000.00 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,659.59 / $2,818.38
| Professional | | $1,023.29 | $1,659.59 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $10,000.00
| Facility | | $10,000.00 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,412.54 / $2,754.23
| Professional | | $1,023.29 | $1,412.54 | $2,754.23 |