- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.05 / $5,031.20 / $12,074.90
| Facility | | $0.05 | $5,031.20 | $12,074.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,000.00 / $5,031.20 / $10,704.00
| Professional | | $2,000.00 | $5,031.20 | $10,704.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,883.31 / $5,131.82 / $19,621.68
| Facility | | $1,883.31 | $5,131.82 | $19,621.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.27 / $846.27 / $4,528.08
| Professional | | $846.27 | $846.27 | $4,528.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,774.60 / $8,502.73 / $14,716.26
| Facility | | $4,774.60 | $8,502.73 | $14,716.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.13 / $5,319.21 / $8,593.75
| Professional | | $2,679.13 | $5,319.21 | $8,593.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,779.64 / $4,779.64 / $6,037.44
| Facility | | $4,779.64 | $4,779.64 | $6,037.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,113.10 / $3,018.72 / $6,540.56
| Professional | | $2,113.10 | $3,018.72 | $6,540.56 |