- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $6,025.60 / $16,982.44
| Facility | | $1,737.80 | $6,025.60 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,698.24 / $4,365.16
| Professional | | $977.24 | $1,698.24 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,630.78 / $7,585.78
| Facility | | $1,548.82 | $3,630.78 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.48 / $100.00 / $5,754.40
| Facility | | $52.48 | $100.00 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $398.11 / $6,606.93
| Professional | | $141.25 | $398.11 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $56.23 / $56.23
| Facility | | $54.95 | $56.23 | $56.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $2,398.83
| Facility | | $1,698.24 | $1,698.24 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $79.43
| Professional | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,584.89 / $6,456.54
| Facility | | $588.84 | $1,584.89 | $6,456.54 |