- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $693.94 / $1,057.83 / $1,269.41
| Facility | | $693.94 | $1,057.83 | $1,269.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.70 / $693.94 / $719.33
| Professional | | $634.70 | $693.94 | $719.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,142.46 / $4,760.27 / $22,849.30
| Facility | | $1,142.46 | $4,760.27 | $22,849.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.52 / $1,142.46 / $119,998.80
| Professional | | $1,015.52 | $1,142.46 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $687.60 / $1,015.52 / $2,538.62
| Facility | | $687.60 | $1,015.52 | $2,538.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,079.02 / $4,079.02 / $4,079.02
| Professional | | $4,079.02 | $4,079.02 | $4,079.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.43 / $423.14 / $1,532.09
| Professional | | $355.43 | $423.14 | $1,532.09 |