- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,513.56 / $2,454.71
| Facility | | $1,000.00 | $1,513.56 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $912.01 / $1,096.48
| Professional | | $707.95 | $912.01 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $6,456.54
| Facility | | $4,677.35 | $4,677.35 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,071.52
| Professional | | $812.83 | $812.83 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Facility | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,318.26 / $1,479.11
| Professional | | $616.60 | $1,318.26 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,951.21 / $10,232.93
| Facility | | $1,230.27 | $2,951.21 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $870.96 / $1,584.89
| Professional | | $691.83 | $870.96 | $1,584.89 |