- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $4,073.80 / $7,762.47
| Facility | | $537.03 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $512.86 / $1,288.25
| Professional | | $398.11 | $512.86 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $758.58 / $6,456.54
| Professional | | $512.86 | $758.58 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $707.95 / $1,412.54
| Professional | | $512.86 | $707.95 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $1,023.29 / $1,202.26
| Professional | | $524.81 | $1,023.29 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $13,489.63 / $26,915.35
| Facility | | $3,311.31 | $13,489.63 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $660.69 / $1,445.44
| Professional | | $380.19 | $660.69 | $1,445.44 |