- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,691.53 / $5,888.44
| Facility | | $933.25 | $2,691.53 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $18,197.01 / $18,197.01
| Professional | | $3,890.45 | $18,197.01 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $27,542.29 / $39,810.72
| Facility | | $15,848.93 | $27,542.29 | $39,810.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,988.33 / $23,988.33 / $23,988.33
| Facility | | $23,988.33 | $23,988.33 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $354.81
| Professional | | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $10,232.93 / $26,302.68
| Facility | | $1,202.26 | $10,232.93 | $26,302.68 |