- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $314.82 / $314.82 / $1,912.88
| Facility | | $314.82 | $314.82 | $1,912.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.45 / $1,083.45 / $10,435.50
| Professional | | $1,083.45 | $1,083.45 | $10,435.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,709.75 / $5,465.55 / $8,669.43
| Facility | | $3,709.75 | $5,465.55 | $8,669.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.76 / $360.76 / $2,688.57
| Professional | | $360.76 | $360.76 | $2,688.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $1,739.00 / $8,038.00
| Facility | | $55.00 | $1,739.00 | $8,038.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,967.58 / $3,652.78 / $12,762.92
| Professional | | $1,967.58 | $3,652.78 | $12,762.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,965.44 / $3,205.13 / $3,987.37
| Professional | | $1,965.44 | $3,205.13 | $3,987.37 |