- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,819.70 / $2,818.38
| Facility | | $776.25 | $1,819.70 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,862.09 / $2,951.21
| Professional | | $1,230.27 | $1,862.09 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $5,370.32
| Professional | | $512.86 | $512.86 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,570.88 / $5,248.07
| Facility | | $4,265.80 | $4,570.88 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $42.66 / $79.43
| Professional | | $21.38 | $42.66 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $3,467.37 / $10,232.93
| Facility | | $954.99 | $3,467.37 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $1,288.25 / $3,019.95
| Professional | | $562.34 | $1,288.25 | $3,019.95 |