- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $4,073.80 / $7,762.47
| Facility | | $602.56 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $575.44 / $1,479.11
| Professional | | $467.74 | $575.44 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $1,659.59 / $7,943.28
| Professional | | $562.34 | $1,659.59 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $724.44 / $1,584.89
| Professional | | $575.44 | $724.44 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,148.15 / $1,318.26
| Professional | | $575.44 | $1,148.15 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $8,128.31 / $26,302.68
| Facility | | $1,023.29 | $8,128.31 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $724.44 / $1,621.81
| Professional | | $426.58 | $724.44 | $1,621.81 |