- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $2,691.53 / $4,365.16
| Facility | | $776.25 | $2,691.53 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $676.08 / $1,318.26
| Professional | | $562.34 | $676.08 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $831.76 / $1,047.13
| Professional | | $676.08 | $831.76 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $794.33 / $1,047.13
| Professional | | $478.63 | $794.33 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $1,230.27 / $6,165.95
| Facility | | $389.05 | $1,230.27 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $794.33 / $1,258.93
| Professional | | $549.54 | $794.33 | $1,258.93 |