- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $4,073.80 / $7,762.47
| Facility | | $645.65 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $616.60 / $1,412.54
| Professional | | $380.19 | $616.60 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,949.84 / $10,715.19
| Professional | | $602.56 | $1,949.84 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $630.96 / $1,412.54
| Professional | | $478.63 | $630.96 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $537.03 / $1,202.26
| Professional | | $512.86 | $537.03 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $16,218.10 / $33,884.42
| Facility | | $4,073.80 | $16,218.10 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $616.60 / $1,380.38
| Professional | | $436.52 | $616.60 | $1,380.38 |