- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $21,877.62 / $66,069.34
| Facility | | $2,089.30 | $21,877.62 | $66,069.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $11,748.98
| Professional | | $1,621.81 | $1,621.81 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27,542.29 / $31,622.78 / $56,234.13
| Facility | | $27,542.29 | $31,622.78 | $56,234.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $23,442.29 / $66,069.34
| Facility | | $2,089.30 | $23,442.29 | $66,069.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $11,748.98
| Professional | | $1,621.81 | $1,621.81 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |