- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $4,786.30 / $8,709.64
| Facility | | $1,000.00 | $4,786.30 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,513.56
| Professional | | $1,000.00 | $1,000.00 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $6,456.54 / $10,000.00
| Professional | | $2,089.30 | $6,456.54 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $21,877.62 / $21,877.62
| Facility | | $5,011.87 | $21,877.62 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Professional | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $4,786.30
| Professional | | $1,548.82 | $1,548.82 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $7,413.10 / $8,511.38
| Facility | | $6,309.57 | $7,413.10 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,467.37 / $7,079.46
| Professional | | $2,454.71 | $3,467.37 | $7,079.46 |