- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $520.36 / $930.70 / $15,587.64
| Facility | | $520.36 | $930.70 | $15,587.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $463.47 / $625.34 / $930.70
| Professional | | $463.47 | $625.34 | $930.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,032.97 / $1,336.84 / $2,198.33
| Professional | | $1,032.97 | $1,336.84 | $2,198.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.70 / $1,370.43 / $2,341.26
| Professional | | $784.70 | $1,370.43 | $2,341.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $520.36 / $930.70 / $1,524.80
| Facility | | $520.36 | $930.70 | $1,524.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.83 / $1,707.37 / $4,785.00
| Professional | | $944.83 | $1,707.37 | $4,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.83 / $1,633.14 / $2,078.63
| Professional | | $944.83 | $1,633.14 | $2,078.63 |