- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $4,073.80 / $7,762.47
| Facility | | $602.56 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $588.84 / $1,513.56
| Professional | | $524.81 | $588.84 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $645.65 / $2,041.74
| Professional | | $478.63 | $645.65 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $812.83 / $1,621.81
| Professional | | $575.44 | $812.83 | $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
- $3,311.31 / $13,489.63 / $26,915.35
| Facility | | $3,311.31 | $13,489.63 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $758.58 / $1,621.81
| Professional | | $446.68 | $758.58 | $1,621.81 |