- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $965.02 / $1,094.58 / $1,232.99
| Facility | | $965.02 | $1,094.58 | $1,232.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $646.80 / $719.24 / $1,094.58
| Professional | | $646.80 | $719.24 | $1,094.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.19 / $780.41 / $1,243.30
| Professional | | $573.19 | $780.41 | $1,243.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $536.72 / $1,803.05 / $3,269.48
| Facility | | $536.72 | $1,803.05 | $3,269.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.25 / $1,336.14 / $2,337.82
| Professional | | $801.25 | $1,336.14 | $2,337.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.66 / $1,177.52 / $1,999.50
| Professional | | $604.66 | $1,177.52 | $1,999.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,742.84 / $2,742.84 / $2,742.84
| Facility | | $2,742.84 | $2,742.84 | $2,742.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $534.16 / $963.65 / $2,043.24
| Professional | | $534.16 | $963.65 | $2,043.24 |