- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $931.36 / $1,748.73 / $2,702.14
| Facility | | $931.36 | $1,748.73 | $2,702.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.70 / $736.25 / $905.51
| Professional | | $634.70 | $736.25 | $905.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.83 / $1,057.83 / $1,057.83
| Professional | | $1,057.83 | $1,057.83 | $1,057.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $748.11 / $1,386.20 / $1,918.68
| Facility | | $748.11 | $1,386.20 | $1,918.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $677.02 / $846.27 / $1,138.50
| Facility | | $677.02 | $846.27 | $1,138.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.43 / $507.76 / $4,214.42
| Professional | | $355.43 | $507.76 | $4,214.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.43 / $507.76 / $1,269.41
| Professional | | $355.43 | $507.76 | $1,269.41 |