- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $805.20 / $8,477.27 / $20,928.72
| Facility | | $805.20 | $8,477.27 | $20,928.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.20 / $805.20 / $805.20
| Professional | | $805.20 | $805.20 | $805.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,003.91 / $9,212.06 / $17,819.09
| Facility | | $7,003.91 | $9,212.06 | $17,819.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $805.20 / $1,368.84 / $4,317.00
| Facility | | $805.20 | $1,368.84 | $4,317.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,054.00 / $4,317.00 / $13,909.00
| Facility | | $3,054.00 | $4,317.00 | $13,909.00 |