- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $2,238.72
| Facility | | $870.96 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $4,466.84 / $6,606.93
| Professional | | $630.96 | $4,466.84 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,135.61 / $17,782.79 / $23,988.33
| Facility | | $15,135.61 | $17,782.79 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $812.83 / $954.99
| Professional | | $575.44 | $812.83 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $6,456.54 / $12,022.64
| Facility | | $2,511.89 | $6,456.54 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $707.95 / $1,348.96
| Professional | | $436.52 | $707.95 | $1,348.96 |