- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $24,547.09 / $58,884.37
| Facility | | $1,778.28 | $24,547.09 | $58,884.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $15,848.93
| Professional | | $1,621.81 | $1,621.81 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41,686.94 / $41,686.94 / $41,686.94
| Facility | | $41,686.94 | $41,686.94 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $10.00 / $11.75
| Professional | | $0.02 | $10.00 | $11.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $50,118.72
| Facility | | $64.57 | $64.57 | $50,118.72 |