- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,888.44 / $16,595.87
| Facility | | $3,801.89 | $5,888.44 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $281.84 / $331.13
| Professional | | $204.17 | $281.84 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $1,096.48 / $1,778.28
| Facility | | $691.83 | $1,096.48 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $575.44 / $1,148.15
| Facility | | $537.03 | $575.44 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Professional | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.42 / $316.23 / $562.34
| Facility | | $234.42 | $316.23 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $6,309.57 / $10,000.00
| Facility | | $616.60 | $6,309.57 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $338.84 / $616.60
| Professional | | $257.04 | $338.84 | $616.60 |