- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $3,388.44 / $6,456.54
| Facility | | $501.19 | $3,388.44 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $467.74 / $1,122.02
| Professional | | $323.59 | $467.74 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $1,819.70 / $5,370.32
| Professional | | $380.19 | $1,819.70 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $616.60 / $1,174.90
| Professional | | $354.81 | $616.60 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $794.33 / $1,122.02
| Professional | | $524.81 | $794.33 | $1,122.02 |
- 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
- $316.23 / $575.44 / $1,122.02
| Professional | | $316.23 | $575.44 | $1,122.02 |