- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $11,481.54 / $26,915.35
| Facility | | $5,370.32 | $11,481.54 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $11,481.54
| Professional | | $8,511.38 | $8,511.38 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $27,542.29 / $66,069.34
| Facility | | $1,047.13 | $27,542.29 | $66,069.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,715.35 / $33,884.42
| Professional | | $1,258.93 | $3,715.35 | $33,884.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $9,772.37 / $17,782.79
| Facility | | $3,388.44 | $9,772.37 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $8,511.38 / $20,417.38
| Professional | | $630.96 | $8,511.38 | $20,417.38 |