- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,630.27 / $3,801.89
| Facility | | $2,454.71 | $2,630.27 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $2,818.38
| Professional | | $1,548.82 | $1,548.82 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,882.50 / $26,302.68 / $74,131.02
| Facility | | $12,882.50 | $26,302.68 | $74,131.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $12,022.64 / $26,915.35
| Facility | | $5,888.44 | $12,022.64 | $26,915.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $10,000.00 / $26,915.35
| Facility | | $1,584.89 | $10,000.00 | $26,915.35 |