- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $4,073.80 / $7,762.47
| Facility | | $630.96 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $630.96 / $2,041.74
| Professional | | $562.34 | $630.96 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $2,398.83 / $10,715.19
| Professional | | $602.56 | $2,398.83 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $870.96 / $1,698.24
| Professional | | $602.56 | $870.96 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,318.26 / $1,412.54
| Professional | | $575.44 | $1,318.26 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $16,218.10 / $33,884.42
| Facility | | $4,073.80 | $16,218.10 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $851.14 / $1,698.24
| Professional | | $524.81 | $851.14 | $1,698.24 |