- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,659.59 / $7,585.78
| Facility | | $1,621.81 | $1,659.59 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,023.29 / $1,258.93
| Professional | | $758.58 | $1,023.29 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,754.23 / $2,754.23
| Facility | | $1,230.27 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,659.59 / $2,754.23
| Professional | | $1,318.26 | $1,659.59 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $10,471.29 / $26,302.68
| Facility | | $134.90 | $10,471.29 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Professional | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,258.93 / $2,570.40
| Facility | | $588.84 | $1,258.93 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $758.58 / $1,318.26
| Professional | | $501.19 | $758.58 | $1,318.26 |