- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $11,220.18 / $18,197.01
| Facility | | $7,943.28 | $11,220.18 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,197.01 / $18,197.01 / $18,197.01
| Professional | | $18,197.01 | $18,197.01 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $22,908.68 / $44,668.36
| Facility | | $2,454.71 | $22,908.68 | $44,668.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $21,379.62
| Facility | | $16,595.87 | $16,595.87 | $21,379.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,197.01 / $26,915.35 / $30,902.95
| Facility | | $18,197.01 | $26,915.35 | $30,902.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $22,387.21 / $37,153.52
| Facility | | $8,317.64 | $22,387.21 | $37,153.52 |