- 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
- $1,758.03 / $1,951.12 / $2,970.13
| Professional | | $1,758.03 | $1,951.12 | $2,970.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.33 / $2,787.77 / $3,425.41
| Professional | | $1,611.33 | $2,787.77 | $3,425.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $521.75 / $2,814.72
| Professional | | $32.34 | $521.75 | $2,814.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,785.46 / $2,272.41 / $2,811.07
| Facility | | $1,785.46 | $2,272.41 | $2,811.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.29 / $2,787.77 / $3,425.41
| Professional | | $2,137.29 | $2,787.77 | $3,425.41 |
- 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
- $2,410.86 / $2,896.29 / $4,145.14
| Professional | | $2,410.86 | $2,896.29 | $4,145.14 |