- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $273.44 / $1,419.24 / $1,419.24
| Facility | | $273.44 | $1,419.24 | $1,419.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,419.24 / $1,500.00
| Professional | | $1,000.00 | $1,419.24 | $1,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.09 / $160.94 / $209.24
| Professional | | $114.09 | $160.94 | $209.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $495.11 / $495.11 / $495.11
| Facility | | $495.11 | $495.11 | $495.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.14 / $705.95 / $1,204.21
| Professional | | $263.14 | $705.95 | $1,204.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $342.37 / $1,419.24 / $3,143.28
| Facility | | $342.37 | $1,419.24 | $3,143.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.00 / $90.00 / $1,971.87
| Professional | | $90.00 | $90.00 | $1,971.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.58 / $128.52 / $1,157.83
| Professional | | $106.58 | $128.52 | $1,157.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.44 / $1,641.50 / $3,645.98
| Professional | | $735.44 | $1,641.50 | $3,645.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $924.23 / $4,442.64 / $5,153.84
| Facility | | $924.23 | $4,442.64 | $5,153.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,302.23 / $10,235.64 / $10,235.64
| Professional | | $5,302.23 | $10,235.64 | $10,235.64 |