- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $5,495.41 / $7,762.47
| Facility | | $776.25 | $5,495.41 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $758.58 / $2,041.74
| Professional | | $676.08 | $758.58 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $2,818.38 / $13,803.84
| Professional | | $776.25 | $2,818.38 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,096.48 / $2,041.74
| Professional | | $741.31 | $1,096.48 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,513.56 / $1,698.24
| Professional | | $724.44 | $1,513.56 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $16,218.10 / $35,481.34
| Facility | | $3,311.31 | $16,218.10 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $977.24 / $2,041.74
| Professional | | $602.56 | $977.24 | $2,041.74 |