- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Facility | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.55 / $61.66 / $2,344.23
| Professional | | $24.55 | $61.66 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $8,511.38 / $77,624.71
| Facility | | $5,011.87 | $8,511.38 | $77,624.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54,954.09 / $64,565.42 / $64,565.42
| Professional | | $54,954.09 | $64,565.42 | $64,565.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.15 / $346.74 / $416.87
| Facility | | $107.15 | $346.74 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Facility | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.55 / $26.92 / $2,344.23
| Professional | | $24.55 | $26.92 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.11 / $436.52 / $3,019.95
| Facility | | $85.11 | $436.52 | $3,019.95 |