- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $555.20 / $730.61 / $6,048.80
| Facility | | $555.20 | $730.61 | $6,048.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.61 / $6,048.80 / $9,148.41
| Professional | | $730.61 | $6,048.80 | $9,148.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,583.14 / $2,004.75 / $13,440.53
| Professional | | $1,583.14 | $2,004.75 | $13,440.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $799.93 / $4,451.28 / $5,123.55
| Professional | | $799.93 | $4,451.28 | $5,123.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,571.00 / $13,350.26 / $26,435.36
| Facility | | $9,571.00 | $13,350.26 | $26,435.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.05 / $3,185.46 / $5,952.76
| Professional | | $357.05 | $3,185.46 | $5,952.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,828.47 / $4,074.56 / $10,790.49
| Professional | | $2,828.47 | $4,074.56 | $10,790.49 |