- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,023.29 / $1,023.29
| Facility | | $398.11 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $8,511.38 / $77,624.71
| Facility | | $5,011.87 | $8,511.38 | $77,624.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64,565.42 / $64,565.42 / $64,565.42
| Professional | | $64,565.42 | $64,565.42 | $64,565.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $954.99 / $1,819.70
| Facility | | $436.52 | $954.99 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,023.29 / $1,023.29
| Facility | | $398.11 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,148.15 / $1,412.54
| Facility | | $602.56 | $1,148.15 | $1,412.54 |