- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,801.89 / $9,772.37
| Facility | | $1,479.11 | $3,801.89 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,047.13 / $2,951.21
| Professional | | $933.25 | $1,047.13 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $16,595.87 / $23,988.33
| Facility | | $9,772.37 | $16,595.87 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,862.09 / $2,691.53
| Professional | | $933.25 | $1,862.09 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $1,995.26 / $3,162.28
| Professional | | $467.74 | $1,995.26 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $10,000.00
| Facility | | $10,000.00 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,698.24 / $2,884.03
| Professional | | $1,047.13 | $1,698.24 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $10,000.00
| Facility | | $10,000.00 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,737.80 / $3,162.28
| Professional | | $1,148.15 | $1,737.80 | $3,162.28 |