- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $4,897.79 / $6,918.31
| Facility | | $257.04 | $4,897.79 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $257.04 / $302.00
| Professional | | $173.78 | $257.04 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $4,897.79 / $6,918.31
| Facility | | $257.04 | $4,897.79 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $257.04 / $288.40
| Professional | | $173.78 | $257.04 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,890.45 / $6,025.60
| Facility | | $851.14 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $338.84 / $457.09
| Professional | | $269.15 | $338.84 | $457.09 |