- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,819.70 / $2,511.89
| Facility | | $1,000.00 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $870.96 / $1,288.25
| Professional | | $758.58 | $870.96 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $9,120.11
| Facility | | $6,760.83 | $6,760.83 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $1,202.26
| Professional | | $891.25 | $891.25 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Facility | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,288.25 / $1,445.44
| Professional | | $707.95 | $1,288.25 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,495.41 / $14,454.40
| Facility | | $2,089.30 | $5,495.41 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,023.29 / $1,548.82
| Professional | | $758.58 | $1,023.29 | $1,548.82 |