- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $35,481.34 / $35,481.34
| Facility | | $812.83 | $35,481.34 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,148.15 / $1,659.59
| Professional | | $812.83 | $1,148.15 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $8,317.64
| Facility | | $1,737.80 | $1,737.80 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Professional | | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,417.38 / $20,417.38 / $20,417.38
| Facility | | $20,417.38 | $20,417.38 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,513.56 / $3,388.44
| Professional | | $870.96 | $1,513.56 | $3,388.44 |