- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $7,838.38 / $7,838.38
| Facility | | $1,000.00 | $7,838.38 | $7,838.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.67 / $1,169.50 / $1,967.39
| Professional | | $1,083.67 | $1,169.50 | $1,967.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.78 / $1,775.06 / $2,248.83
| Professional | | $1,377.78 | $1,775.06 | $2,248.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $346.32 / $1,864.44
| Professional | | $32.34 | $346.32 | $1,864.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.30 / $1,536.56 / $1,747.03
| Facility | | $1,207.30 | $1,536.56 | $1,747.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.78 / $1,797.11 / $2,248.83
| Professional | | $1,377.78 | $1,797.11 | $2,248.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,085.00 / $4,262.00 / $17,636.00
| Facility | | $3,085.00 | $4,262.00 | $17,636.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,371.05 / $1,848.08 / $2,772.63
| Professional | | $1,371.05 | $1,848.08 | $2,772.63 |