- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,467.37 / $6,606.93
| Facility | | $933.25 | $3,467.37 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,754.40 / $7,943.28
| Professional | | $4,466.84 | $5,754.40 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $7,079.46 / $8,912.51
| Professional | | $5,754.40 | $7,079.46 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Facility | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $1,230.27 / $6,165.95
| Facility | | $389.05 | $1,230.27 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $6,165.95 / $10,715.19
| Professional | | $4,073.80 | $6,165.95 | $10,715.19 |