- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,630.78 / $6,606.93
| Facility | | $1,000.00 | $3,630.78 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,073.80 / $6,606.93
| Professional | | $3,548.13 | $4,073.80 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,677.35 / $5,754.40
| Professional | | $3,715.35 | $4,677.35 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $3,715.35 / $7,244.36
| Facility | | $489.78 | $3,715.35 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,677.35 / $29,512.09
| Professional | | $3,467.37 | $4,677.35 | $29,512.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,949.84 / $6,165.95
| Facility | | $346.74 | $1,949.84 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,073.80 / $6,309.57
| Professional | | $3,311.31 | $4,073.80 | $6,309.57 |