- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $4,365.16
| Facility | | $549.54 | $549.54 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $562.34 / $1,819.70
| Professional | | $512.86 | $562.34 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Professional | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $912.01 / $2,691.53
| Facility | | $741.31 | $912.01 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $2,884.03 / $7,079.46
| Professional | | $524.81 | $2,884.03 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Professional | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $2,454.71 / $5,248.07
| Professional | | $724.44 | $2,454.71 | $5,248.07 |