- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $816.22 / $1,532.53 / $2,368.06
| Facility | | $816.22 | $1,532.53 | $2,368.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $556.23 / $556.23 / $741.64
| Professional | | $556.23 | $556.23 | $741.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.05 / $927.05 / $927.05
| Professional | | $927.05 | $927.05 | $927.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $593.30 / $741.64 / $997.73
| Facility | | $593.30 | $741.64 | $997.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.49 / $444.98 / $3,693.37
| Professional | | $311.49 | $444.98 | $3,693.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.49 / $444.98 / $1,112.46
| Professional | | $311.49 | $444.98 | $1,112.46 |