- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,370.32 / $8,511.38
| Facility | | $1,412.54 | $5,370.32 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $18,197.01 / $18,197.01
| Professional | | $1,445.44 | $18,197.01 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $354.81
| Professional | | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $4,786.30 / $8,511.38
| Facility | | $1,023.29 | $4,786.30 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $5,011.87 / $18,197.01
| Professional | | $707.95 | $5,011.87 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $8,128.31 / $56,234.13
| Facility | | $3,311.31 | $8,128.31 | $56,234.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $16,218.10
| Professional | | $16,218.10 | $16,218.10 | $16,218.10 |