- 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
- $1,685.78 / $1,877.90 / $3,544.33
| Professional | | $1,685.78 | $1,877.90 | $3,544.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,037.04 / $3,474.74 / $3,804.34
| Professional | | $2,037.04 | $3,474.74 | $3,804.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $3,028.36
| Professional | | $32.34 | $32.34 | $3,028.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,389.44 / $3,474.74 / $3,804.34
| Professional | | $2,389.44 | $3,474.74 | $3,804.34 |
- 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
- $2,779.27 / $3,901.65 / $4,890.88
| Professional | | $2,779.27 | $3,901.65 | $4,890.88 |