- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $764.13 / $1,273.82 / $17,902.59
| Facility | | $764.13 | $1,273.82 | $17,902.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.34 / $3,079.48 / $19,777.20
| Professional | | $880.34 | $3,079.48 | $19,777.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,796.13 / $10,796.13 / $12,955.36
| Facility | | $10,796.13 | $10,796.13 | $12,955.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.85 / $846.84 / $11,070.84
| Professional | | $575.85 | $846.84 | $11,070.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,986.00 / $8,986.00 / $8,986.00
| Facility | | $8,986.00 | $8,986.00 | $8,986.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,264.37 / $13,590.21 / $19,983.70
| Professional | | $10,264.37 | $13,590.21 | $19,983.70 |