- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,241.22 / $10,431.19 / $20,928.72
| Facility | | $4,241.22 | $10,431.19 | $20,928.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.13 / $186.13 / $186.13
| Professional | | $186.13 | $186.13 | $186.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,937.84 / $8,047.30 / $15,106.84
| Facility | | $5,937.84 | $8,047.30 | $15,106.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.37 / $1,063.55 / $1,063.55
| Professional | | $1,010.37 | $1,063.55 | $1,063.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.13 / $316.42 / $1,476.40
| Facility | | $186.13 | $316.42 | $1,476.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.68 / $2,713.22 / $2,713.22
| Professional | | $748.68 | $2,713.22 | $2,713.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $301.31 / $571.37 / $1,183.28
| Facility | | $301.31 | $571.37 | $1,183.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.20 / $748.68 / $1,134.98
| Professional | | $370.20 | $748.68 | $1,134.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.40 / $208.40 / $229.50
| Professional | | $208.40 | $208.40 | $229.50 |