- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $4,073.80 / $7,762.47
| Facility | | $691.83 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $691.83 / $1,862.09
| Professional | | $630.96 | $691.83 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,380.38 / $2,454.71
| Professional | | $588.84 | $1,380.38 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $758.58 / $1,737.80
| Professional | | $616.60 | $758.58 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $1,348.96
| Professional | | $575.44 | $602.56 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $14,454.40 / $26,302.68
| Facility | | $2,344.23 | $14,454.40 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $741.31 / $1,659.59
| Professional | | $524.81 | $741.31 | $1,659.59 |