- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $862.86 / $1,035.43 / $1,035.43
| Facility | | $862.86 | $1,035.43 | $1,035.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.72 / $586.75 / $586.75
| Professional | | $517.72 | $586.75 | $586.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $931.89 / $3,882.88 / $18,637.84
| Facility | | $931.89 | $3,882.88 | $18,637.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.35 / $931.89 / $119,998.80
| Professional | | $828.35 | $931.89 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $560.86 / $828.35 / $2,070.69
| Facility | | $560.86 | $828.35 | $2,070.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,327.20 / $3,327.20 / $3,327.20
| Professional | | $3,327.20 | $3,327.20 | $3,327.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.92 / $345.15 / $1,000.92
| Professional | | $289.92 | $345.15 | $1,000.92 |