- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $5,128.61 / $6,918.31
| Facility | | $588.84 | $5,128.61 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $501.19 / $1,047.13
| Professional | | $371.54 | $501.19 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $1,230.27 / $5,495.41
| Professional | | $416.87 | $1,230.27 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $501.19 / $1,288.25
| Professional | | $371.54 | $501.19 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $575.44 / $1,047.13
| Professional | | $489.78 | $575.44 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $4,786.30 / $26,302.68
| Facility | | $1,023.29 | $4,786.30 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $436.52 / $1,122.02
| Professional | | $316.23 | $436.52 | $1,122.02 |