- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $9,120.11 / $16,595.87
| Facility | | $912.01 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $912.01 / $977.24
| Professional | | $575.44 | $912.01 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $5,623.41 / $10,000.00
| Facility | | $2,238.72 | $5,623.41 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Professional | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $954.99 / $1,621.81
| Facility | | $630.96 | $954.99 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $17,378.01 / $25,703.96
| Facility | | $2,884.03 | $17,378.01 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,122.02 / $1,778.28
| Professional | | $831.76 | $1,122.02 | $1,778.28 |