- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,041.74 / $4,570.88
| Facility | | $758.58 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $446.68 / $741.31
| Professional | | $346.74 | $446.68 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $9,772.37 / $14,454.40
| Facility | | $5,754.40 | $9,772.37 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $501.19 / $630.96
| Professional | | $407.38 | $501.19 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $8,511.38 / $8,511.38
| Facility | | $39.81 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $562.34 / $741.31
| Professional | | $331.13 | $562.34 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $6,456.54 / $13,489.63
| Facility | | $1,202.26 | $6,456.54 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $446.68 / $741.31
| Professional | | $331.13 | $446.68 | $741.31 |