- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $5,495.41 / $7,762.47
| Facility | | $831.76 | $5,495.41 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $812.83 / $2,238.72
| Professional | | $724.44 | $812.83 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $3,715.35 / $13,182.57
| Professional | | $794.33 | $3,715.35 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $2,238.72
| Professional | | $812.83 | $1,174.90 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,621.81 / $1,862.09
| Professional | | $794.33 | $1,621.81 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $16,218.10 / $35,481.34
| Facility | | $3,311.31 | $16,218.10 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,047.13 / $2,238.72
| Professional | | $645.65 | $1,047.13 | $2,238.72 |