- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $4,073.80 / $7,762.47
| Facility | | $676.08 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $676.08 / $812.83
| Professional | | $371.54 | $676.08 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $2,137.96 / $5,370.32
| Professional | | $588.84 | $2,137.96 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $676.08 / $1,380.38
| Professional | | $524.81 | $676.08 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,202.26 / $1,202.26
| Professional | | $1,096.48 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,737.80 / $15,848.93
| Facility | | $741.31 | $1,737.80 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $776.25 / $1,548.82
| Professional | | $512.86 | $776.25 | $1,548.82 |