- 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
- $1,010.40 / $1,165.40 / $1,701.66
| Professional | | $1,010.40 | $1,165.40 | $1,701.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,294.96 / $1,294.96 / $1,294.96
| Facility | | $1,294.96 | $1,294.96 | $1,294.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.52 / $1,657.47 / $2,099.27
| Professional | | $1,165.52 | $1,657.47 | $2,099.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $1,802.71
| Professional | | $32.34 | $32.34 | $1,802.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,105.96 / $1,382.93 / $1,707.32
| Facility | | $1,105.96 | $1,382.93 | $1,707.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,270.73 / $1,767.97 / $2,953.65
| Professional | | $1,270.73 | $1,767.97 | $2,953.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $755.00 / $4,616.00 / $17,636.00
| Facility | | $755.00 | $4,616.00 | $17,636.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.57 / $1,688.11 / $2,389.14
| Professional | | $1,194.57 | $1,688.11 | $2,389.14 |