- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $10,964.78 / $28,840.32
| Facility | | $1,778.28 | $10,964.78 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $19,054.61
| Professional | | $933.25 | $933.25 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $17,782.79 / $38,018.94
| Facility | | $7,762.47 | $17,782.79 | $38,018.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,803.84 / $23,988.33 / $44,668.36
| Facility | | $13,803.84 | $23,988.33 | $44,668.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Professional | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $22,387.21 / $41,686.94
| Facility | | $7,413.10 | $22,387.21 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.85 / $15.85 / $15.85
| Professional | | $15.85 | $15.85 | $15.85 |