- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,584.89 / $2,818.38
| Facility | | $741.31 | $1,584.89 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,466.84 / $5,754.40
| Professional | | $1,202.26 | $4,466.84 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Professional | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $16,595.87
| Facility | | $16,595.87 | $16,595.87 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.02 / $42.66 / $50.12
| Professional | | $38.02 | $42.66 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $9,332.54 / $19,054.61
| Facility | | $1,348.96 | $9,332.54 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,348.96 / $2,454.71
| Professional | | $891.25 | $1,348.96 | $2,454.71 |