- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $7,762.47 / $7,762.47
| Facility | | $1,949.84 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,949.84 / $2,630.27
| Professional | | $1,548.82 | $1,949.84 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56,234.13 / $69,183.10 / $81,283.05
| Facility | | $56,234.13 | $69,183.10 | $81,283.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $85.11
| Professional | | $60.26 | $60.26 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.93 / $2,238.72 / $3,715.35
| Facility | | $208.93 | $2,238.72 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $6,606.93 / $16,982.44
| Facility | | $645.65 | $6,606.93 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,981.07 / $5,888.44
| Professional | | $2,951.21 | $3,981.07 | $5,888.44 |