- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $5,370.32 / $22,387.21
| Facility | | $2,398.83 | $5,370.32 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $891.25 / $2,691.53
| Professional | | $812.83 | $891.25 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,623.41 / $8,912.51
| Facility | | $5,011.87 | $5,623.41 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,698.24 / $2,454.71
| Professional | | $812.83 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $1,778.28 / $2,754.23
| Professional | | $389.05 | $1,778.28 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,479.11 / $2,570.40
| Professional | | $933.25 | $1,479.11 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,621.81 / $2,818.38
| Professional | | $1,000.00 | $1,621.81 | $2,818.38 |