- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,511.89 / $11,481.54
| Facility | | $2,398.83 | $2,511.89 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $758.58 / $1,949.84
| Professional | | $630.96 | $758.58 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $15,135.61 / $23,988.33
| Facility | | $5,623.41 | $15,135.61 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,258.93 / $1,778.28
| Professional | | $630.96 | $1,258.93 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $1,348.96 / $2,089.30
| Professional | | $467.74 | $1,348.96 | $2,089.30 |
- 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
- $707.95 / $1,148.15 / $1,949.84
| Professional | | $707.95 | $1,148.15 | $1,949.84 |
- 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
- $776.25 / $1,148.15 / $2,089.30
| Professional | | $776.25 | $1,148.15 | $2,089.30 |