- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $2,290.87 / $4,073.80
| Facility | | $616.60 | $2,290.87 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $549.54 / $1,096.48
| Professional | | $407.38 | $549.54 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $6,606.93 / $9,772.37
| Facility | | $2,187.76 | $6,606.93 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $794.33 / $1,202.26
| Professional | | $549.54 | $794.33 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Facility | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $676.08 / $1,122.02
| Professional | | $467.74 | $676.08 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $28,840.32
| Facility | | $16,595.87 | $16,595.87 | $28,840.32 |
- 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 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,630.78 / $6,309.57
| Facility | | $2,041.74 | $3,630.78 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $602.56 / $1,023.29
| Professional | | $416.87 | $602.56 | $1,023.29 |