- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $10,232.93 / $28,183.83
| Facility | | $1,318.26 | $10,232.93 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $10,232.93
| Professional | | $676.08 | $676.08 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $16,595.87 / $19,952.62
| Facility | | $10,715.19 | $16,595.87 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $8,317.64 / $16,218.10
| Facility | | $4,677.35 | $8,317.64 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Professional | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $199.53 / $346.74
| Professional | | $120.23 | $199.53 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $10,232.93 / $29,512.09
| Facility | | $2,570.40 | $10,232.93 | $29,512.09 |