- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $471.06 / $2,778.87 / $3,955.04
| Facility | | $471.06 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.02 / $621.21 / $751.57
| Professional | | $482.02 | $621.21 | $751.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.48 / $831.02 / $1,164.63
| Professional | | $648.48 | $831.02 | $1,164.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.41 / $908.24 / $1,649.04
| Professional | | $758.41 | $908.24 | $1,649.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.26 / $895.19 / $1,505.98
| Professional | | $630.26 | $895.19 | $1,505.98 |