- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $5,623.41 / $7,943.28
| Facility | | $295.12 | $5,623.41 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Professional | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $186.21
| Professional | | $186.21 | $186.21 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,290.87 / $12,882.50
| Facility | | $1,412.54 | $2,290.87 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $190.55 / $190.55
| Professional | | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $50.12 / $79.43
| Professional | | $21.38 | $50.12 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $12,022.64 / $18,620.87
| Facility | | $5,495.41 | $12,022.64 | $18,620.87 |