- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,981.07 / $6,456.54
| Facility | | $933.25 | $3,981.07 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.98 / $660.69 / $660.69
| Professional | | $48.98 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $2,398.83 / $6,456.54
| Professional | | $676.08 | $2,398.83 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,691.53
| Professional | | $2,398.83 | $2,398.83 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $14,791.08 / $26,915.35
| Facility | | $3,311.31 | $14,791.08 | $26,915.35 |