- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $2,398.83 / $9,772.37
| Facility | | $501.19 | $2,398.83 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $630.96
| Professional | | $186.21 | $186.21 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $12,022.64 / $22,908.68
| Facility | | $10,964.78 | $12,022.64 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |