- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $4,073.80 / $7,762.47
| Facility | | $954.99 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $851.14 / $2,238.72
| Professional | | $724.44 | $851.14 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $2,398.83 / $7,943.28
| Professional | | $912.01 | $2,398.83 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $977.24 / $2,454.71
| Professional | | $812.83 | $977.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,862.09 / $2,137.96
| Professional | | $912.01 | $1,862.09 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $14,791.08 / $26,915.35
| Facility | | $3,311.31 | $14,791.08 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $912.01 / $1,995.26
| Professional | | $691.83 | $912.01 | $1,995.26 |