- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,897.79 / $11,220.18
| Facility | | $1,584.89 | $4,897.79 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $19,054.61 / $19,054.61
| Professional | | $3,019.95 | $19,054.61 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $7,413.10 / $26,915.35
| Facility | | $3,801.89 | $7,413.10 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $316.23 / $331.13
| Professional | | $295.12 | $316.23 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $323.59 / $21,379.62
| Facility | | $64.57 | $323.59 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Professional | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $10,964.78 / $25,703.96
| Facility | | $3,630.78 | $10,964.78 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,317.64 / $25,703.96 / $41,686.94
| Professional | | $8,317.64 | $25,703.96 | $41,686.94 |