- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $466.83 / $710.00 / $2,729.67
| Facility | | $466.83 | $710.00 | $2,729.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.30 / $466.83 / $497.00
| Professional | | $376.30 | $466.83 | $497.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $362.69 / $1,041.93 / $1,757.25
| Facility | | $362.69 | $1,041.93 | $1,757.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.10 / $887.20 / $1,170.08
| Professional | | $362.10 | $887.20 | $1,170.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.50 / $1,293.61 / $1,753.70
| Professional | | $816.50 | $1,293.61 | $1,753.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.60 / $426.00 / $1,245.98
| Professional | | $326.60 | $426.00 | $1,245.98 |