- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $17,782.79 / $39,810.72
| Facility | | $4,073.80 | $17,782.79 | $39,810.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $7,762.47
| Professional | | $676.08 | $676.08 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,248.07 / $25,118.86
| Facility | | $2,454.71 | $5,248.07 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $8,511.38 / $8,511.38
| Professional | | $1,318.26 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $11,748.98 / $26,302.68
| Facility | | $7,244.36 | $11,748.98 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Professional | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $16,218.10
| Professional | | $16,218.10 | $16,218.10 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $9,332.54 / $23,442.29
| Facility | | $2,884.03 | $9,332.54 | $23,442.29 |