- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $10,000.00 / $20,417.38
| Facility | | $1,949.84 | $10,000.00 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $758.58 / $1,949.84
| Professional | | $588.84 | $758.58 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $912.01 / $2,137.96
| Professional | | $630.96 | $912.01 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,023.29 / $3,388.44
| Facility | | $645.65 | $1,023.29 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,041.74 / $3,981.07
| Professional | | $1,445.44 | $2,041.74 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,630.27 / $3,801.89
| Professional | | $1,548.82 | $2,630.27 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,047.13 / $3,388.44
| Facility | | $660.69 | $1,047.13 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $954.99 / $2,137.96
| Professional | | $60.26 | $954.99 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,737.80 / $4,168.69
| Professional | | $602.56 | $1,737.80 | $4,168.69 |