- 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
- $159.74 / $528.16 / $32,926.00
| Facility | | $159.74 | $528.16 | $32,926.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.37 / $363.28 / $748.22
| Professional | | $296.37 | $363.28 | $748.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.36 / $363.28 / $544.92
| Professional | | $296.36 | $363.28 | $544.92 |