- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $7,762.47 / $16,595.87
| Facility | | $3,801.89 | $7,762.47 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $2,089.30 / $2,089.30
| Professional | | $169.82 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $10,715.19 / $19,498.45
| Facility | | $6,165.95 | $10,715.19 | $19,498.45 |
- 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
- $8,709.64 / $20,417.38 / $25,703.96
| Facility | | $8,709.64 | $20,417.38 | $25,703.96 |