- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $2,691.53 / $3,235.94
| Facility | | $478.63 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $380.19 / $1,949.84
| Professional | | $151.36 | $380.19 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $478.63 / $1,230.27
| Professional | | $158.49 | $478.63 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,754.23 / $17,782.79
| Facility | | $2,570.40 | $2,754.23 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Facility | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $363.08 / $1,584.89
| Professional | | $158.49 | $363.08 | $1,584.89 |