- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,897.79 / $10,964.78
| Facility | | $1,584.89 | $4,897.79 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $4,265.80 / $11,748.98
| Professional | | $1,000.00 | $4,265.80 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $9,120.11 / $17,378.01
| Facility | | $3,801.89 | $9,120.11 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $512.86 / $1,047.13
| Professional | | $371.54 | $512.86 | $1,047.13 |
- 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
- $831.76 / $831.76 / $831.76
| Professional | | $831.76 | $831.76 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $10,964.78 / $26,302.68
| Facility | | $2,290.87 | $10,964.78 | $26,302.68 |