- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.68 / $10,480.93 / $11,727.90
| Facility | | $234.68 | $10,480.93 | $11,727.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,160.84 / $5,160.84 / $5,311.60
| Professional | | $5,160.84 | $5,160.84 | $5,311.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.91 / $3,467.91 / $3,467.91
| Professional | | $3,467.91 | $3,467.91 | $3,467.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,160.84 / $5,160.84 / $8,670.20
| Facility | | $5,160.84 | $5,160.84 | $8,670.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.00 / $155.00 / $329.00
| Professional | | $155.00 | $155.00 | $329.00 |