- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $3,162.28
| Facility | | $2,344.23 | $2,344.23 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,344.23 / $3,162.28
| Professional | | $1,698.24 | $2,344.23 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,481.54 / $30,902.95 / $58,884.37
| Facility | | $11,481.54 | $30,902.95 | $58,884.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $302.00 / $316.23
| Professional | | $218.78 | $302.00 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $2,818.38 / $4,168.69
| Professional | | $302.00 | $2,818.38 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $338.84 / $512.86
| Professional | | $125.89 | $338.84 | $512.86 |
- 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
- $144.54 / $1,000.00 / $2,691.53
| Facility | | $144.54 | $1,000.00 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,778.28 / $2,754.23
| Professional | | $1,258.93 | $1,778.28 | $2,754.23 |