- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,290.87 / $8,511.38
| Facility | | $794.33 | $2,290.87 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $8,511.38
| Professional | | $5,495.41 | $5,495.41 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $7,244.36 / $7,244.36
| Facility | | $5,888.44 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $239.88 / $269.15
| Professional | | $204.17 | $239.88 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $56,234.13 / $83,176.38
| Facility | | $12,302.69 | $56,234.13 | $83,176.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74,131.02 / $74,131.02 / $104,712.85
| Professional | | $74,131.02 | $74,131.02 | $104,712.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $44.67 / $44.67
| Professional | | $44.67 | $44.67 | $44.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $5,011.87 / $12,302.69
| Facility | | $977.24 | $5,011.87 | $12,302.69 |