- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $455.43 / $2,753.25 / $10,585.10
| Facility | | $455.43 | $2,753.25 | $10,585.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.43 / $455.43 / $455.43
| Professional | | $455.43 | $455.43 | $455.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $196.85 / $3,549.77 / $6,814.29
| Facility | | $196.85 | $3,549.77 | $6,814.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,193.53 / $1,651.95 / $3,026.37
| Professional | | $1,193.53 | $1,651.95 | $3,026.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,114.39 / $8,855.48 / $15,801.86
| Facility | | $4,114.39 | $8,855.48 | $15,801.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,166.24 / $5,016.42 / $6,800.53
| Professional | | $3,166.24 | $5,016.42 | $6,800.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.50 / $1,651.95 / $4,831.68
| Professional | | $1,266.50 | $1,651.95 | $4,831.68 |