- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,786.30 / $11,220.18
| Facility | | $1,584.89 | $4,786.30 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $4,168.69 / $11,481.54
| Professional | | $1,000.00 | $4,168.69 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $8,317.64 / $16,982.44
| Facility | | $3,890.45 | $8,317.64 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $1,621.81 / $3,162.28
| Professional | | $245.47 | $1,621.81 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $21,379.62 / $53,703.18
| Facility | | $323.59 | $21,379.62 | $53,703.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Professional | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,162.28 / $10,232.93
| Facility | | $851.14 | $3,162.28 | $10,232.93 |