- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $6,606.93 / $14,125.38
| Facility | | $1,412.54 | $6,606.93 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $2,290.87
| Professional | | $1,096.48 | $1,096.48 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,318.26 / $2,818.38
| Professional | | $1,071.52 | $1,318.26 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $11,748.98 / $53,703.18
| Facility | | $398.11 | $11,748.98 | $53,703.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $1,819.70
| Professional | | $933.25 | $933.25 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $11,748.98 / $22,908.68
| Facility | | $5,754.40 | $11,748.98 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $512.86 / $794.33
| Professional | | $39.81 | $512.86 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $10,000.00 / $15,848.93
| Facility | | $2,818.38 | $10,000.00 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $39.81 / $60.26
| Professional | | $34.67 | $39.81 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $446.68 / $446.68
| Professional | | $446.68 | $446.68 | $446.68 |