- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $705.76 / $1,227.06 / $5,889.29
| Facility | | $705.76 | $1,227.06 | $5,889.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.63 / $1,331.39 / $2,421.00
| Professional | | $164.63 | $1,331.39 | $2,421.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.00 / $610.00 / $4,301.00
| Professional | | $394.00 | $610.00 | $4,301.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.32 / $366.44 / $2,328.66
| Professional | | $210.32 | $366.44 | $2,328.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.89 / $1,310.18 / $3,361.74
| Professional | | $262.89 | $1,310.18 | $3,361.74 |