- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $12,022.64 / $16,595.87
| Facility | | $9,772.37 | $12,022.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $190.55 / $229.09
| Professional | | $141.25 | $190.55 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.22 / $154.88 / $331.13
| Facility | | $16.22 | $154.88 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $223.87 / $234.42
| Professional | | $141.25 | $223.87 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $758.58 / $1,000.00
| Professional | | $416.87 | $758.58 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.22 / $154.88 / $331.13
| Facility | | $16.22 | $154.88 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $61.66 / $446.68
| Professional | | $61.66 | $61.66 | $446.68 |