- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,235.94 / $7,762.47
| Facility | | $1,047.13 | $3,235.94 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,584.89 / $8,709.64
| Professional | | $707.95 | $1,584.89 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $15,135.61 / $21,877.62
| Facility | | $7,943.28 | $15,135.61 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,479.11 / $9,120.11
| Professional | | $933.25 | $1,479.11 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Facility | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,380.38 / $9,332.54
| Professional | | $741.31 | $1,380.38 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $9,332.54 / $22,387.21
| Facility | | $1,202.26 | $9,332.54 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,621.81 / $9,332.54
| Professional | | $724.44 | $1,621.81 | $9,332.54 |