- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $4,897.79 / $16,218.10
| Facility | | $912.01 | $4,897.79 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $812.83 / $1,380.38
| Professional | | $707.95 | $812.83 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $18,620.87 / $26,302.68
| Facility | | $9,549.93 | $18,620.87 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,047.13 / $1,659.59
| Professional | | $776.25 | $1,047.13 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $1,819.70
| Professional | | $812.83 | $1,096.48 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $7,762.47 / $10,964.78
| Facility | | $3,090.30 | $7,762.47 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $912.01 / $1,479.11
| Professional | | $758.58 | $912.01 | $1,479.11 |