- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,819.70 / $4,365.16
| Facility | | $776.25 | $1,819.70 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,495.41 / $10,471.29
| Professional | | $4,365.16 | $5,495.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $8,709.64
| Professional | | $8,709.64 | $8,709.64 | $8,709.64 |
- 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 / $8,912.51
| Facility | | $724.44 | $1,445.44 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,888.44 / $10,715.19
| Professional | | $3,715.35 | $5,888.44 | $10,715.19 |