- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,888.44 / $12,882.50
| Facility | | $1,949.84 | $5,888.44 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $15,135.61 / $15,135.61
| Professional | | $3,235.94 | $15,135.61 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $12,022.64 / $24,547.09
| Facility | | $5,248.07 | $12,022.64 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $331.13 / $20,892.96
| Professional | | $295.12 | $331.13 | $20,892.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $398.11 / $15,488.17
| Facility | | $64.57 | $398.11 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $9,120.11 / $20,892.96
| Facility | | $2,951.21 | $9,120.11 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,182.57 / $38,018.94 / $56,234.13
| Professional | | $13,182.57 | $38,018.94 | $56,234.13 |