- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $657.87 / $657.87 / $3,706.14
| Facility | | $657.87 | $657.87 | $3,706.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.36 / $567.14 / $812.01
| Professional | | $477.36 | $567.14 | $812.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.92 / $629.69 / $1,049.43
| Professional | | $482.92 | $629.69 | $1,049.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.30 / $852.08 / $1,114.30
| Professional | | $657.30 | $852.08 | $1,114.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.00 / $2,445.00 / $4,602.00
| Facility | | $1,388.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $469.60 / $775.58 / $1,197.23
| Professional | | $469.60 | $775.58 | $1,197.23 |