- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $3,162.28 / $7,762.47
| Facility | | $524.81 | $3,162.28 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $501.19 / $1,288.25
| Professional | | $446.68 | $501.19 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $1,071.52 / $4,073.80
| Professional | | $512.86 | $1,071.52 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $660.69 / $1,412.54
| Professional | | $512.86 | $660.69 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $1,000.00 / $1,174.90
| Professional | | $512.86 | $1,000.00 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $6,606.93 / $26,302.68
| Facility | | $1,023.29 | $6,606.93 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $645.65 / $1,412.54
| Professional | | $371.54 | $645.65 | $1,412.54 |