- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,090.30 / $8,511.38
| Facility | | $1,148.15 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,466.84 / $5,623.41
| Professional | | $3,090.30 | $4,466.84 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,791.08 / $16,595.87 / $19,952.62
| Facility | | $14,791.08 | $16,595.87 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $199.53 / $1,621.81
| Professional | | $120.23 | $199.53 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $9,772.37 / $25,703.96
| Facility | | $2,570.40 | $9,772.37 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,412.54 / $3,388.44
| Professional | | $977.24 | $1,412.54 | $3,388.44 |