- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,897.79 / $18,620.87
| Facility | | $2,344.23 | $4,897.79 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,890.45 / $3,890.45
| Professional | | $3,801.89 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,982.44 / $40,738.03 / $57,543.99
| Facility | | $16,982.44 | $40,738.03 | $57,543.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.90 / $67.61 / $162.18
| Professional | | $38.90 | $67.61 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $10,471.29 / $10,471.29
| Facility | | $10,471.29 | $10,471.29 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $11,220.18 / $17,378.01
| Facility | | $5,128.61 | $11,220.18 | $17,378.01 |