- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $5,128.61 / $7,762.47
| Facility | | $630.96 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $630.96 / $794.33
| Professional | | $371.54 | $630.96 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $2,238.72 / $6,456.54
| Professional | | $295.12 | $2,238.72 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $660.69 / $1,288.25
| Professional | | $436.52 | $660.69 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,122.02
| Professional | | $1,071.52 | $1,071.52 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $12,882.50 / $26,915.35
| Facility | | $3,311.31 | $12,882.50 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $724.44 / $1,513.56
| Professional | | $501.19 | $724.44 | $1,513.56 |