- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,090.30 / $3,090.30
| Facility | | $1,258.93 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $1,513.56
| Professional | | $1,000.00 | $1,288.25 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56,234.13 / $69,183.10 / $81,283.05
| Facility | | $56,234.13 | $69,183.10 | $81,283.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $85.11
| Professional | | $60.26 | $60.26 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Facility | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.14 / $15.14 / $15.14
| Professional | | $15.14 | $15.14 | $15.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,737.80 / $1,737.80
| Facility | | $794.33 | $1,737.80 | $1,737.80 |