- 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
- $363.08 / $575.44 / $1,288.25
| Professional | | $363.08 | $575.44 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $1,819.70 / $4,073.80
| Professional | | $446.68 | $1,819.70 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $588.84 / $1,318.26
| Professional | | $446.68 | $588.84 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $512.86 / $1,148.15
| Professional | | $489.78 | $512.86 | $1,148.15 |
- 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
- $407.38 / $602.56 / $1,288.25
| Professional | | $407.38 | $602.56 | $1,288.25 |