- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $5,623.41 / $6,918.31
| Facility | | $602.56 | $5,623.41 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $616.60 / $1,905.46
| Professional | | $416.87 | $616.60 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $4,677.35 / $9,120.11
| Professional | | $707.95 | $4,677.35 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $794.33 / $1,548.82
| Professional | | $549.54 | $794.33 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $575.44 / $1,380.38
| Professional | | $549.54 | $575.44 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $13,489.63 / $41,686.94
| Facility | | $4,897.79 | $13,489.63 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $776.25 / $1,584.89
| Professional | | $512.86 | $776.25 | $1,584.89 |