- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,168.69 / $15,848.93
| Facility | | $2,398.83 | $4,168.69 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,412.54 / $2,041.74
| Professional | | $1,174.90 | $1,412.54 | $2,041.74 |
- 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
- $1,202.26 / $2,454.71 / $3,801.89
| Professional | | $1,202.26 | $2,454.71 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,398.83 / $4,073.80
| Professional | | $1,737.80 | $2,398.83 | $4,073.80 |
- 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
- $1,479.11 / $2,398.83 / $4,073.80
| Professional | | $1,479.11 | $2,398.83 | $4,073.80 |
- 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
- $1,479.11 / $2,041.74 / $3,981.07
| Professional | | $1,479.11 | $2,041.74 | $3,981.07 |