- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,344.23 / $5,623.41
| Facility | | $1,737.80 | $2,344.23 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,258.93 / $1,479.11
| Professional | | $1,000.00 | $1,258.93 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $4,570.88
| Facility | | $1,513.56 | $1,513.56 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $239.88 / $501.19
| Professional | | $204.17 | $239.88 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $21,877.62 / $33,113.11
| Facility | | $1,479.11 | $21,877.62 | $33,113.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $5,888.44
| Facility | | $977.24 | $977.24 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $1,862.09 / $4,570.88
| Professional | | $316.23 | $1,862.09 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Facility | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $912.01 / $1,513.56
| Professional | | $630.96 | $912.01 | $1,513.56 |