- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $5,128.61 / $7,762.47
| Facility | | $645.65 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $645.65 / $1,584.89
| Professional | | $416.87 | $645.65 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $4,677.35 / $9,120.11
| Professional | | $588.84 | $4,677.35 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $724.44 / $1,380.38
| Professional | | $524.81 | $724.44 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $501.19 / $1,230.27
| Professional | | $478.63 | $501.19 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $16,218.10 / $33,884.42
| Facility | | $3,311.31 | $16,218.10 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $707.95 / $1,380.38
| Professional | | $478.63 | $707.95 | $1,380.38 |