- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $5,495.41 / $7,762.47
| Facility | | $933.25 | $5,495.41 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $912.01 / $2,454.71
| Professional | | $812.83 | $912.01 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $3,548.13 / $46,773.51
| Professional | | $933.25 | $3,548.13 | $46,773.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,318.26 / $2,511.89
| Professional | | $891.25 | $1,318.26 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,819.70 / $2,089.30
| Professional | | $870.96 | $1,819.70 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $13,489.63 / $41,686.94
| Facility | | $4,897.79 | $13,489.63 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,174.90 / $2,511.89
| Professional | | $724.44 | $1,174.90 | $2,511.89 |