- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,456.54 / $9,772.37
| Facility | | $3,981.07 | $6,456.54 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $22,908.68 / $22,908.68
| Professional | | $2,818.38 | $22,908.68 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,782.79 / $31,622.78 / $81,283.05
| Facility | | $17,782.79 | $31,622.78 | $81,283.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $12,022.64 / $29,512.09
| Facility | | $5,888.44 | $12,022.64 | $29,512.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $10,000.00 / $28,840.32
| Facility | | $1,584.89 | $10,000.00 | $28,840.32 |