- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $511.82 / $3,243.94 / $5,605.66
| Facility | | $511.82 | $3,243.94 | $5,605.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.64 / $547.00 / $865.49
| Professional | | $305.64 | $547.00 | $865.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.53 / $587.32 / $904.98
| Professional | | $331.53 | $587.32 | $904.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.06 / $670.52 / $1,181.41
| Professional | | $437.06 | $670.52 | $1,181.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,806.00 / $3,465.00 / $5,510.00
| Facility | | $1,806.00 | $3,465.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.07 / $796.66 / $1,270.25
| Professional | | $516.07 | $796.66 | $1,270.25 |