- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $368.46 / $2,081.80 / $10,922.00
| Facility | | $368.46 | $2,081.80 | $10,922.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $368.46 / $368.46 / $379.59
| Professional | | $368.46 | $368.46 | $379.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,135.25 / $19,037.08 / $30,907.88
| Facility | | $10,135.25 | $19,037.08 | $30,907.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,493.49 / $18,585.30 / $21,130.93
| Facility | | $15,493.49 | $18,585.30 | $21,130.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.87 / $89.26 / $89.26
| Professional | | $75.87 | $89.26 | $89.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,745.63 / $26,662.15 / $32,148.90
| Facility | | $14,745.63 | $26,662.15 | $32,148.90 |