- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $4,073.80 / $4,570.88
| Facility | | $602.56 | $4,073.80 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $295.12 / $1,778.28
| Professional | | $269.15 | $295.12 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $1,949.84 / $7,943.28
| Professional | | $295.12 | $1,949.84 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $398.11 / $2,238.72
| Professional | | $263.03 | $398.11 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $245.47 / $562.34
| Professional | | $229.09 | $245.47 | $562.34 |
- 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
- $234.42 / $338.84 / $724.44
| Professional | | $234.42 | $338.84 | $724.44 |