- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,630.78 / $10,471.29
| Facility | | $891.25 | $3,630.78 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Professional | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $8,912.51 / $8,912.51
| Facility | | $7,244.36 | $8,912.51 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41,686.94 / $52,480.75 / $56,234.13
| Facility | | $41,686.94 | $52,480.75 | $56,234.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46,773.51 / $46,773.51 / $51,286.14
| Professional | | $46,773.51 | $46,773.51 | $51,286.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $2,754.23 / $6,309.57
| Facility | | $602.56 | $2,754.23 | $6,309.57 |