- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,162.28 / $7,762.47
| Facility | | $602.56 | $3,162.28 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $602.56 / $1,949.84
| Professional | | $436.52 | $602.56 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $741.31 / $9,120.11
| Professional | | $478.63 | $741.31 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $691.83 / $1,621.81
| Professional | | $512.86 | $691.83 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,230.27 / $1,318.26
| Professional | | $575.44 | $1,230.27 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $8,128.31 / $26,302.68
| Facility | | $1,023.29 | $8,128.31 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $831.76 / $1,659.59
| Professional | | $363.08 | $831.76 | $1,659.59 |