- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $367.36 / $367.36 / $1,901.94
| Facility | | $367.36 | $367.36 | $1,901.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $452.56 / $680.60 / $4,271.37
| Professional | | $452.56 | $680.60 | $4,271.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,328.00 / $15,806.00 / $19,757.00
| Facility | | $15,328.00 | $15,806.00 | $19,757.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.12 / $727.98 / $2,978.24
| Professional | | $294.12 | $727.98 | $2,978.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.44 / $1,301.44 / $1,734.64
| Professional | | $1,301.44 | $1,301.44 | $1,734.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.11 / $1,685.41 / $3,300.31
| Professional | | $1,049.11 | $1,685.41 | $3,300.31 |