- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $5,754.40 / $12,882.50
| Facility | | $1,819.70 | $5,754.40 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $34,673.69 / $34,673.69
| Professional | | $3,630.78 | $34,673.69 | $34,673.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $11,748.98 / $26,915.35
| Facility | | $5,623.41 | $11,748.98 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $295.12 / $331.13
| Professional | | $0.02 | $295.12 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $12,589.25 / $23,442.29
| Facility | | $64.57 | $12,589.25 | $23,442.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $12,022.64 / $28,840.32
| Facility | | $3,630.78 | $12,022.64 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,000.00 / $29,512.09 / $61,659.50
| Professional | | $10,000.00 | $29,512.09 | $61,659.50 |