- 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
- $3,548.13 / $8,709.64 / $16,982.44
| Facility | | $3,548.13 | $8,709.64 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $977.24 / $2,041.74
| Professional | | $794.33 | $977.24 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,982.44 / $26,915.35 / $35,481.34
| Facility | | $16,982.44 | $26,915.35 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Professional | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $11,220.18 / $28,840.32
| Facility | | $2,290.87 | $11,220.18 | $28,840.32 |