- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,174.90 / $1,513.56
| Facility | | $776.25 | $1,174.90 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $870.96 / $1,778.28
| Professional | | $691.83 | $870.96 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,230.27 / $2,630.27
| Professional | | $707.95 | $1,230.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,202.26 / $1,548.82
| Professional | | $1,096.48 | $1,202.26 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,786.30 / $7,585.78
| Facility | | $3,090.30 | $4,786.30 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $912.01 / $2,754.23
| Professional | | $562.34 | $912.01 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,128.61 / $8,511.38
| Facility | | $2,570.40 | $5,128.61 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $933.25 / $2,187.76
| Professional | | $630.96 | $933.25 | $2,187.76 |