- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $10,964.78 / $25,703.96
| Facility | | $4,897.79 | $10,964.78 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,309.57 / $25,703.96
| Professional | | $5,011.87 | $6,309.57 | $25,703.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,630.78 / $7,585.78
| Facility | | $1,548.82 | $3,630.78 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.07 / $1,659.59 / $12,302.69
| Facility | | $66.07 | $1,659.59 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $1,698.24
| Professional | | $398.11 | $398.11 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $56.23 / $56.23
| Facility | | $54.95 | $56.23 | $56.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,884.03 / $7,943.28
| Facility | | $1,412.54 | $2,884.03 | $7,943.28 |