- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.26 / $3,706.14 / $4,026.21
| Facility | | $3,438.26 | $3,706.14 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,154.57 / $15,154.57 / $15,154.57
| Professional | | $15,154.57 | $15,154.57 | $15,154.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,546.26 / $27,273.62 / $33,885.86
| Facility | | $24,546.26 | $27,273.62 | $33,885.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.02
| Professional | | $0.02 | $0.02 | $0.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |