- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.84 / $2,186.88 / $3,464.33
| Facility | | $575.84 | $2,186.88 | $3,464.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,524.30 / $1,563.38 / $3,117.00
| Professional | | $1,524.30 | $1,563.38 | $3,117.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.01 / $201.99 / $473.83
| Facility | | $61.01 | $201.99 | $473.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.48 / $263.05 / $1,172.58
| Professional | | $193.48 | $263.05 | $1,172.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $224.23 / $224.23 / $224.23
| Facility | | $224.23 | $224.23 | $224.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.48 / $252.55 / $351.85
| Professional | | $193.48 | $252.55 | $351.85 |