- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $2,884.03 / $7,762.47
| Facility | | $446.68 | $2,884.03 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $2,884.03 / $6,456.54
| Professional | | $162.18 | $2,884.03 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $3,235.94 / $7,079.46
| Professional | | $177.83 | $3,235.94 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $2,187.76 / $6,760.83
| Professional | | $173.78 | $2,187.76 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $3,019.95 / $6,456.54
| Professional | | $389.05 | $3,019.95 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $16,218.10 / $33,884.42
| Facility | | $4,073.80 | $16,218.10 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $501.19 / $7,244.36
| Professional | | $165.96 | $501.19 | $7,244.36 |