- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $421.08 / $1,052.70 / $4,544.47
| Facility | | $421.08 | $1,052.70 | $4,544.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.08 / $619.70 / $675.32
| Professional | | $421.08 | $619.70 | $675.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.61 / $1,005.03 / $2,679.47
| Facility | | $776.61 | $1,005.03 | $2,679.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.21 / $1,040.78 / $1,447.56
| Professional | | $834.21 | $1,040.78 | $1,447.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $556.14 / $556.14 / $8,702.00
| Facility | | $556.14 | $556.14 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $556.14 / $556.14 / $556.14
| Professional | | $556.14 | $556.14 | $556.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.60 / $476.69 / $810.38
| Professional | | $307.60 | $476.69 | $810.38 |