- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $2,187.76 / $4,073.80
| Facility | | $776.25 | $2,187.76 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,122.02 / $2,398.83
| Professional | | $912.01 | $1,122.02 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $6,606.93 / $9,772.37
| Facility | | $2,187.76 | $6,606.93 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,621.81 / $2,454.71
| Professional | | $1,122.02 | $1,621.81 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Facility | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,412.54 / $2,238.72
| Professional | | $1,000.00 | $1,412.54 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $28,840.32
| Facility | | $16,595.87 | $16,595.87 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $9,120.11
| Professional | | $9,120.11 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,754.40 / $10,232.93
| Facility | | $3,235.94 | $5,754.40 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,230.27 / $2,089.30
| Professional | | $870.96 | $1,230.27 | $2,089.30 |