- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $2,290.87 / $19,498.45
| Facility | | $954.99 | $2,290.87 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $6,456.54
| Professional | | $676.08 | $676.08 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $14,125.38 / $19,054.61
| Facility | | $11,748.98 | $14,125.38 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $12,022.64 / $22,908.68
| Facility | | $5,248.07 | $12,022.64 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Professional | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $7,413.10 / $26,302.68
| Facility | | $2,511.89 | $7,413.10 | $26,302.68 |