- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $2,754.23 / $4,073.80
| Facility | | $575.44 | $2,754.23 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $549.54 / $1,380.38
| Professional | | $457.09 | $549.54 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $1,071.52 / $4,073.80
| Professional | | $501.19 | $1,071.52 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $724.44 / $1,412.54
| Professional | | $512.86 | $724.44 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,096.48 / $1,288.25
| Professional | | $660.69 | $1,096.48 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $6,606.93 / $26,302.68
| Facility | | $1,023.29 | $6,606.93 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $707.95 / $1,412.54
| Professional | | $416.87 | $707.95 | $1,412.54 |