- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $9,120.11 / $16,595.87
| Facility | | $831.76 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $933.25
| Professional | | $831.76 | $831.76 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $371.54 / $891.25
| Professional | | $346.74 | $371.54 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,000.00 / $1,737.80
| Facility | | $831.76 | $1,000.00 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $54.95
| Professional | | $30.20 | $30.20 | $54.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $6,760.83 / $9,120.11
| Facility | | $2,454.71 | $6,760.83 | $9,120.11 |