- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $4,073.80 / $7,762.47
| Facility | | $501.19 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $478.63 / $1,230.27
| Professional | | $426.58 | $478.63 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $575.44 / $2,818.38
| Professional | | $426.58 | $575.44 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $575.44 / $1,348.96
| Professional | | $467.74 | $575.44 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $977.24 / $1,122.02
| Professional | | $501.19 | $977.24 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $549.54 / $4,168.69
| Facility | | $213.80 | $549.54 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $616.60 / $1,348.96
| Professional | | $354.81 | $616.60 | $1,348.96 |