- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,819.70 / $3,548.13
| Facility | | $776.25 | $1,819.70 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,981.07 / $8,709.64
| Professional | | $3,090.30 | $3,981.07 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Professional | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,495.41 / $7,585.78
| Professional | | $3,235.94 | $5,495.41 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,445.44 / $4,073.80
| Facility | | $724.44 | $1,445.44 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,890.45 / $8,511.38
| Professional | | $2,951.21 | $3,890.45 | $8,511.38 |