- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,137.96 / $7,762.47
| Facility | | $933.25 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $933.25 / $2,454.71
| Professional | | $891.25 | $933.25 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,023.29 / $1,202.26
| Professional | | $912.01 | $1,023.29 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,174.90 / $2,398.83
| Professional | | $831.76 | $1,174.90 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,905.46 / $2,089.30
| Professional | | $912.01 | $1,905.46 | $2,089.30 |
- 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 / $1,174.90 / $2,454.71
| Professional | | $724.44 | $1,174.90 | $2,454.71 |