- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $11,481.54 / $24,547.09
| Facility | | $4,897.79 | $11,481.54 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $1,122.02 / $4,265.80
| Professional | | $316.23 | $1,122.02 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $8,511.38 / $15,488.17
| Facility | | $4,897.79 | $8,511.38 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $54.95
| Professional | | $30.20 | $30.20 | $54.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $17,378.01 / $26,302.68
| Facility | | $6,309.57 | $17,378.01 | $26,302.68 |