- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,560.08 / $1,560.08 / $26,688.70
| Facility | | $1,560.08 | $1,560.08 | $26,688.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.00 / $5,863.00 / $11,456.00
| Facility | | $2,137.00 | $5,863.00 | $11,456.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,062.37 / $7,651.34 / $12,882.22
| Facility | | $4,062.37 | $7,651.34 | $12,882.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.67 / $309.54 / $5,476.61
| Professional | | $235.67 | $309.54 | $5,476.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.67 / $2,507.96 / $6,162.45
| Professional | | $268.67 | $2,507.96 | $6,162.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $6,199.92 / $6,199.92
| Facility | | $55.00 | $6,199.92 | $6,199.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.45 / $671.66 / $6,422.22
| Facility | | $307.45 | $671.66 | $6,422.22 |