- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $10,715.19 / $10,715.19
| Facility | | $1,000.00 | $10,715.19 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,023.29 / $5,888.44
| Professional | | $1,000.00 | $1,023.29 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $831.76 / $2,041.74
| Facility | | $501.19 | $831.76 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,288.25 / $2,089.30
| Professional | | $891.25 | $1,288.25 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Professional | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,202.26 / $2,187.76
| Facility | | $1,000.00 | $1,202.26 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,258.93
| Professional | | $1,023.29 | $1,023.29 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,698.24
| Facility | | $1,023.29 | $1,023.29 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,096.48 / $1,096.48
| Professional | | $1,023.29 | $1,096.48 | $1,096.48 |