- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $11,481.54 / $28,183.83
| Facility | | $4,677.35 | $11,481.54 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $3,801.89 / $28,183.83
| Professional | | $1,412.54 | $3,801.89 | $28,183.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,620.87 / $19,498.45 / $37,153.52
| Facility | | $18,620.87 | $19,498.45 | $37,153.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $75.86 / $75.86
| Professional | | $75.86 | $75.86 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,782.79 / $17,782.79 / $22,387.21
| Facility | | $17,782.79 | $17,782.79 | $22,387.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,071.52 / $25,118.86
| Facility | | $501.19 | $1,071.52 | $25,118.86 |