- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,168.69 / $9,772.37
| Facility | | $1,122.02 | $4,168.69 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $15,488.17 / $15,488.17
| Professional | | $2,089.30 | $15,488.17 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,620.87 / $26,302.68 / $31,622.78
| Facility | | $18,620.87 | $26,302.68 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $10,000.00
| Professional | | $10,000.00 | $10,000.00 | $10,000.00 |
- 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 / $9,772.37 / $26,302.68
| Facility | | $2,570.40 | $9,772.37 | $26,302.68 |