- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,370.32 / $10,000.00
| Facility | | $2,137.96 | $5,370.32 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $1,995.26 / $6,760.83
| Professional | | $177.83 | $1,995.26 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $15,135.61 / $28,183.83
| Facility | | $7,762.47 | $15,135.61 | $28,183.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $2,137.96
| Facility | | $794.33 | $794.33 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $10,232.93
| Professional | | $1,445.44 | $1,445.44 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,265.80
| Professional | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $12,022.64 / $18,620.87
| Facility | | $7,413.10 | $12,022.64 | $18,620.87 |