- 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
- $1,319.55 / $1,446.64 / $2,479.44
| Professional | | $1,319.55 | $1,446.64 | $2,479.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,430.70 / $2,429.87 / $3,061.78
| Professional | | $1,430.70 | $2,429.87 | $3,061.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $2,125.05
| Professional | | $32.34 | $32.34 | $2,125.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,671.54 / $2,006.58 / $3,061.78
| Professional | | $1,671.54 | $2,006.58 | $3,061.78 |
- 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
- $1,946.77 / $2,443.41 / $3,305.79
| Professional | | $1,946.77 | $2,443.41 | $3,305.79 |