- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,570.40 / $11,481.54
| Facility | | $2,398.83 | $2,570.40 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $724.44 / $1,995.26
| Professional | | $630.96 | $724.44 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,332.54 / $10,471.29 / $19,952.62
| Facility | | $9,332.54 | $10,471.29 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,258.93 / $1,819.70
| Professional | | $630.96 | $1,258.93 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $1,348.96 / $2,137.96
| Professional | | $467.74 | $1,348.96 | $2,137.96 |
- 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 / $1,995.26
| Professional | | $707.95 | $1,148.15 | $1,995.26 |
- 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
- $812.83 / $1,202.26 / $2,187.76
| Professional | | $812.83 | $1,202.26 | $2,187.76 |