- 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
- $2,166.69 / $2,350.32 / $4,086.82
| Professional | | $2,166.69 | $2,350.32 | $4,086.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,634.60 / $3,436.44 / $5,173.09
| Professional | | $2,634.60 | $3,436.44 | $5,173.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $832.73 / $4,462.87
| Professional | | $32.34 | $832.73 | $4,462.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,365.16 / $3,010.20 / $3,494.84
| Facility | | $2,365.16 | $3,010.20 | $3,494.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,634.60 / $3,589.61 / $5,173.09
| Professional | | $2,634.60 | $3,589.61 | $5,173.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,085.00 / $3,503.00 / $15,732.00
| Facility | | $3,085.00 | $3,503.00 | $15,732.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,876.85 / $4,120.80 / $5,772.30
| Professional | | $2,876.85 | $4,120.80 | $5,772.30 |