- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,495.41 / $8,709.64
| Facility | | $1,412.54 | $5,495.41 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $22,908.68 / $22,908.68
| Professional | | $1,445.44 | $22,908.68 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $38,018.94 / $52,480.75
| Facility | | $7,585.78 | $38,018.94 | $52,480.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $4,786.30 / $8,511.38
| Facility | | $1,023.29 | $4,786.30 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $5,011.87 / $22,908.68
| Professional | | $707.95 | $5,011.87 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,495.41 / $35,481.34
| Facility | | $2,454.71 | $5,495.41 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Professional | | $5,011.87 | $5,011.87 | $5,011.87 |