- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $22,908.68 / $30,902.95
| Facility | | $371.54 | $22,908.68 | $30,902.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Professional | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $63.10 / $63.10
| Professional | | $60.26 | $63.10 | $63.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $18,620.87 / $21,877.62
| Facility | | $316.23 | $18,620.87 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Professional | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $5,888.44
| Facility | | $5,888.44 | $5,888.44 | $5,888.44 |