- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $4,073.80 / $6,918.31
| Facility | | $741.31 | $4,073.80 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $660.69 / $1,621.81
| Professional | | $501.19 | $660.69 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $4,073.80 / $8,128.31
| Professional | | $467.74 | $4,073.80 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $741.31 / $1,412.54
| Professional | | $467.74 | $741.31 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $707.95 / $1,412.54
| Professional | | $676.08 | $707.95 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $16,218.10 / $33,884.42
| Facility | | $4,073.80 | $16,218.10 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $691.83 / $1,445.44
| Professional | | $446.68 | $691.83 | $1,445.44 |