- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $552.75 / $912.01 / $4,736.00
| Facility | | $552.75 | $912.01 | $4,736.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.08 / $344.05 / $433.61
| Professional | | $215.08 | $344.05 | $433.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.81 / $356.44 / $506.70
| Professional | | $239.81 | $356.44 | $506.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,443.37 / $2,443.37 / $2,443.37
| Facility | | $2,443.37 | $2,443.37 | $2,443.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.04 / $360.04 / $360.04
| Professional | | $360.04 | $360.04 | $360.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.25 / $418.56 / $920.83
| Professional | | $288.25 | $418.56 | $920.83 |