- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $7,762.47 / $12,302.69
| Facility | | $2,187.76 | $7,762.47 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,778.28 / $2,187.76
| Professional | | $1,479.11 | $1,778.28 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $6,309.57 / $10,715.19
| Facility | | $2,818.38 | $6,309.57 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.88 / $12.88 / $1,621.81
| Professional | | $12.88 | $12.88 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,445.44 / $6,760.83
| Facility | | $1,174.90 | $1,445.44 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,630.27 / $3,162.28
| Professional | | $2,511.89 | $2,630.27 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Professional | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Professional | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $1,621.81
| Professional | | $933.25 | $933.25 | $1,621.81 |