- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $994.20 / $1,410.63 / $3,393.46
| Facility | | $994.20 | $1,410.63 | $3,393.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.46 / $638.15 / $1,671.61
| Professional | | $212.46 | $638.15 | $1,671.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $783.24 / $1,243.71 / $2,672.01
| Facility | | $783.24 | $1,243.71 | $2,672.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.43 / $593.45 / $1,359.09
| Professional | | $196.43 | $593.45 | $1,359.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.12 / $336.60 / $943.92
| Facility | | $134.12 | $336.60 | $943.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.00 / $2,108.69 / $2,108.69
| Professional | | $762.00 | $2,108.69 | $2,108.69 |