- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $4,073.80 / $7,762.47
| Facility | | $512.86 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $645.65 / $1,513.56
| Professional | | $512.86 | $645.65 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $3,548.13 / $7,943.28
| Professional | | $630.96 | $3,548.13 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $691.83 / $1,621.81
| Professional | | $575.44 | $691.83 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $630.96 / $1,412.54
| Professional | | $588.84 | $630.96 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $13,489.63 / $26,302.68
| Facility | | $2,344.23 | $13,489.63 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $724.44 / $1,548.82
| Professional | | $524.81 | $724.44 | $1,548.82 |