- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,137.96 / $7,762.47
| Facility | | $645.65 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $645.65 / $1,479.11
| Professional | | $173.78 | $645.65 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $1,023.29 / $1,380.38
| Professional | | $112.20 | $1,023.29 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $3,019.95
| Professional | | $1,412.54 | $1,412.54 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,344.23 / $16,218.10
| Facility | | $645.65 | $2,344.23 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $1,258.93 / $2,691.53
| Professional | | $436.52 | $1,258.93 | $2,691.53 |