- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $5,754.40 / $11,481.54
| Facility | | $2,238.72 | $5,754.40 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,174.90 / $10,471.29
| Professional | | $831.76 | $1,174.90 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $34.67 / $53,703.18
| Facility | | $34.67 | $34.67 | $53,703.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50,118.72 / $53,703.18 / $75,857.76
| Facility | | $50,118.72 | $53,703.18 | $75,857.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $398.11
| Professional | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,754.23 / $4,897.79
| Facility | | $1,318.26 | $2,754.23 | $4,897.79 |