- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $4,265.80 / $9,772.37
| Facility | | $741.31 | $4,265.80 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $1,071.52 / $2,290.87
| Professional | | $204.17 | $1,071.52 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $6,456.54 / $15,848.93
| Professional | | $309.03 | $6,456.54 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $741.31 / $2,398.83
| Professional | | $269.15 | $741.31 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $3,162.28 / $3,162.28
| Professional | | $645.65 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $13,489.63 / $41,686.94
| Facility | | $4,897.79 | $13,489.63 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $870.96 / $3,388.44
| Professional | | $275.42 | $870.96 | $3,388.44 |