- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,071.52 / $1,445.44
| Facility | | $1,000.00 | $1,071.52 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,047.13 / $1,584.89
| Professional | | $794.33 | $1,047.13 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,348.96 / $1,348.96
| Professional | | $691.83 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $2,754.23 / $4,786.30
| Facility | | $870.96 | $2,754.23 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,348.96
| Professional | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $6,309.57
| Facility | | $6,309.57 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $10,000.00 / $10,000.00
| Professional | | $6,606.93 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $1,348.96 / $1,348.96
| Facility | | $478.63 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $794.33 / $1,348.96
| Professional | | $562.34 | $794.33 | $1,348.96 |