- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $601.16 / $2,211.19 / $3,616.69
| Facility | | $601.16 | $2,211.19 | $3,616.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.87 / $561.16 / $701.45
| Professional | | $420.87 | $561.16 | $701.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $720.82 / $1,662.12 / $32,926.00
| Facility | | $720.82 | $1,662.12 | $32,926.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.42 / $123.88 / $521.65
| Professional | | $104.42 | $123.88 | $521.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.97 / $123.88 / $257.64
| Professional | | $103.97 | $123.88 | $257.64 |