- 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
- $1,182.28 / $1,279.86 / $2,457.78
| Professional | | $1,182.28 | $1,279.86 | $2,457.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.57 / $2,133.36 / $2,701.56
| Professional | | $1,445.57 | $2,133.36 | $2,701.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $432.04 / $2,329.17
| Professional | | $32.34 | $432.04 | $2,329.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,340.32 / $1,705.87 / $2,044.30
| Facility | | $1,340.32 | $1,705.87 | $2,044.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,635.58 / $2,133.36 / $2,701.56
| Professional | | $1,635.58 | $2,133.36 | $2,701.56 |
- 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
- $1,666.58 / $2,133.19 / $3,368.79
| Professional | | $1,666.58 | $2,133.19 | $3,368.79 |