- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $4,073.80 / $4,570.88
| Facility | | $478.63 | $4,073.80 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $478.63 / $1,148.15
| Professional | | $407.38 | $478.63 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $1,202.26 / $2,454.71
| Professional | | $467.74 | $1,202.26 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $616.60 / $1,318.26
| Professional | | $467.74 | $616.60 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,000.00 / $1,202.26
| Professional | | $588.84 | $1,000.00 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,737.80 / $7,943.28
| Facility | | $741.31 | $1,737.80 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $602.56 / $1,288.25
| Professional | | $354.81 | $602.56 | $1,288.25 |