- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $5,128.61 / $7,762.47
| Facility | | $616.60 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $588.84 / $1,513.56
| Professional | | $537.03 | $588.84 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $8,128.31 / $16,218.10
| Professional | | $616.60 | $8,128.31 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $741.31 / $1,621.81
| Professional | | $588.84 | $741.31 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,174.90 / $1,348.96
| Professional | | $575.44 | $1,174.90 | $1,348.96 |
- 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
- $436.52 / $758.58 / $1,621.81
| Professional | | $436.52 | $758.58 | $1,621.81 |