- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $462.61 / $4,035.46 / $4,035.46
| Facility | | $462.61 | $4,035.46 | $4,035.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $465.36 / $637.41 / $942.44
| Professional | | $465.36 | $637.41 | $942.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.42 / $1,201.54 / $1,714.23
| Professional | | $928.42 | $1,201.54 | $1,714.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $725.78 / $1,329.87 / $2,181.02
| Professional | | $725.78 | $1,329.87 | $2,181.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $462.61 / $786.44 / $1,387.83
| Facility | | $462.61 | $786.44 | $1,387.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.08 / $1,371.53 / $3,482.72
| Professional | | $743.08 | $1,371.53 | $3,482.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.08 / $1,295.33 / $1,634.78
| Professional | | $743.08 | $1,295.33 | $1,634.78 |