- 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
- $2,733.72 / $2,830.56 / $5,485.77
| Professional | | $2,733.72 | $2,830.56 | $5,485.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,290.10 / $4,681.51 / $6,038.90
| Professional | | $3,290.10 | $4,681.51 | $6,038.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $971.16 / $5,198.72
| Professional | | $32.34 | $971.16 | $5,198.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,836.87 / $3,610.56 / $4,227.54
| Facility | | $2,836.87 | $3,610.56 | $4,227.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,589.15 / $4,681.51 / $6,038.90
| Professional | | $3,589.15 | $4,681.51 | $6,038.90 |
- 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
- $3,512.00 / $4,846.56 / $7,640.87
| Professional | | $3,512.00 | $4,846.56 | $7,640.87 |