- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $758.58 / $1,737.80
| Professional | | $645.65 | $758.58 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $831.76 / $1,047.13
| Professional | | $741.31 | $831.76 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Facility | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $912.01 / $1,659.59
| Professional | | $660.69 | $912.01 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $812.83 / $1,318.26
| Professional | | $724.44 | $812.83 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $707.95 / $2,238.72
| Facility | | $588.84 | $707.95 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $831.76 / $1,513.56
| Professional | | $588.84 | $831.76 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $870.96 / $1,122.02
| Professional | | $645.65 | $870.96 | $1,122.02 |