- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $5,754.40 / $12,882.50
| Facility | | $1,862.09 | $5,754.40 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $15,848.93 / $15,848.93
| Professional | | $3,630.78 | $15,848.93 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $12,302.69 / $28,840.32
| Facility | | $5,888.44 | $12,302.69 | $28,840.32 |
- 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
- $16,218.10 / $46,773.51 / $69,183.10
| Professional | | $16,218.10 | $46,773.51 | $69,183.10 |