- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $4,073.80 / $7,762.47
| Facility | | $602.56 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $776.25 / $1,995.26
| Professional | | $602.56 | $776.25 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $2,570.40 / $6,456.54
| Professional | | $776.25 | $2,570.40 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $954.99 / $1,862.09
| Professional | | $660.69 | $954.99 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $691.83 / $1,621.81
| Professional | | $660.69 | $691.83 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $16,218.10 / $36,307.81
| Facility | | $3,311.31 | $16,218.10 | $36,307.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $891.25 / $1,778.28
| Professional | | $630.96 | $891.25 | $1,778.28 |