- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $5,495.41 / $10,964.78
| Facility | | $239.88 | $5,495.41 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $1,548.82 / $6,760.83
| Professional | | $169.82 | $1,548.82 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $512.86 / $35,481.34
| Facility | | $323.59 | $512.86 | $35,481.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $4,168.69
| Facility | | $4,168.69 | $4,168.69 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $6,025.60 / $16,982.44
| Facility | | $1,513.56 | $6,025.60 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,232.93 / $10,232.93 / $10,232.93
| Facility | | $10,232.93 | $10,232.93 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,630.78 / $3,630.78
| Professional | | $2,754.23 | $3,630.78 | $3,630.78 |