- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $6,025.60 / $11,748.98
| Facility | | $3,235.94 | $6,025.60 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $7,585.78 / $8,912.51
| Professional | | $549.54 | $7,585.78 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,197.01 / $33,113.11 / $69,183.10
| Facility | | $18,197.01 | $33,113.11 | $69,183.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,912.51 / $11,748.98 / $16,982.44
| Professional | | $8,912.51 | $11,748.98 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,488.17 / $15,488.17 / $15,488.17
| Professional | | $15,488.17 | $15,488.17 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $8,912.51 / $11,220.18
| Professional | | $660.69 | $8,912.51 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,489.63 / $19,054.61 / $32,359.37
| Facility | | $13,489.63 | $19,054.61 | $32,359.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,230.27 / $3,388.44
| Professional | | $741.31 | $1,230.27 | $3,388.44 |