- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $676.08 / $1,288.25
| Facility | | $501.19 | $676.08 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $645.65 / $851.14
| Professional | | $501.19 | $645.65 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,412.54 / $1,621.81
| Professional | | $1,047.13 | $1,412.54 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,047.13
| Professional | | $812.83 | $812.83 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $851.14 / $3,388.44
| Facility | | $501.19 | $851.14 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $363.08 / $1,202.26
| Professional | | $302.00 | $363.08 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $707.95 / $1,023.29
| Professional | | $302.00 | $707.95 | $1,023.29 |