- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $4,365.16 / $9,549.93
| Facility | | $316.23 | $4,365.16 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $2,137.96
| Professional | | $316.23 | $316.23 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $4,786.30 / $4,786.30
| Facility | | $2,041.74 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $64.57 / $199.53
| Professional | | $60.26 | $64.57 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $562.34
| Facility | | $64.57 | $64.57 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Professional | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,801.89 / $6,760.83
| Facility | | $1,862.09 | $3,801.89 | $6,760.83 |