- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $3,162.28 / $7,762.47
| Facility | | $616.60 | $3,162.28 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $524.81 / $851.14
| Professional | | $371.54 | $524.81 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $1,230.27 / $2,454.71
| Professional | | $478.63 | $1,230.27 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $467.74 / $1,348.96
| Professional | | $363.08 | $467.74 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $524.81 / $1,096.48
| Professional | | $457.09 | $524.81 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $549.54 / $11,481.54
| Facility | | $213.80 | $549.54 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $436.52 / $1,174.90
| Professional | | $302.00 | $436.52 | $1,174.90 |