- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,586.20
| Facility | | $1,000.00 | $1,000.00 | $1,586.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,580.45 / $1,600.00
| Professional | | $1,000.00 | $1,580.45 | $1,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,120.71 / $2,516.01 / $2,605.87
| Professional | | $2,120.71 | $2,516.01 | $2,605.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $451.04 / $2,013.25 / $2,798.66
| Professional | | $451.04 | $2,013.25 | $2,798.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $384.92 / $1,300.00 / $2,197.00
| Facility | | $384.92 | $1,300.00 | $2,197.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.35 / $2,646.97 / $9,962.67
| Professional | | $983.35 | $2,646.97 | $9,962.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,532.45 / $2,592.58 / $3,829.89
| Professional | | $1,532.45 | $2,592.58 | $3,829.89 |