- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $2,137.96 / $7,762.47
| Facility | | $676.08 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $831.76 / $2,238.72
| Professional | | $676.08 | $831.76 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $933.25 / $1,230.27
| Professional | | $831.76 | $933.25 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,071.52 / $2,089.30
| Professional | | $758.58 | $1,071.52 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $794.33 / $1,862.09
| Professional | | $741.31 | $794.33 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,344.23 / $16,218.10
| Facility | | $645.65 | $2,344.23 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,023.29 / $2,041.74
| Professional | | $724.44 | $1,023.29 | $2,041.74 |