- 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
- $1,146.55 / $1,275.89 / $1,941.11
| Professional | | $1,146.55 | $1,275.89 | $1,941.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.56 / $1,816.27 / $2,283.85
| Professional | | $1,050.56 | $1,816.27 | $2,283.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $340.72 / $1,839.54
| Professional | | $32.34 | $340.72 | $1,839.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,198.05 / $1,524.80 / $1,835.66
| Facility | | $1,198.05 | $1,524.80 | $1,835.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.47 / $1,816.27 / $2,283.85
| Professional | | $1,392.47 | $1,816.27 | $2,283.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,085.00 / $3,503.00 / $15,732.00
| Facility | | $3,085.00 | $3,503.00 | $15,732.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.75 / $1,883.75 / $2,701.81
| Professional | | $1,472.75 | $1,883.75 | $2,701.81 |