- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $713.50 / $4,072.98 / $12,099.85
| Facility | | $713.50 | $4,072.98 | $12,099.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.59 / $818.23 / $1,584.82
| Professional | | $227.59 | $818.23 | $1,584.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.02 / $718.98 / $1,997.68
| Professional | | $241.02 | $718.98 | $1,997.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,834.48 / $3,834.48 / $3,834.48
| Facility | | $3,834.48 | $3,834.48 | $3,834.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.42 / $228.42 / $228.42
| Professional | | $228.42 | $228.42 | $228.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.07 / $1,477.26 / $3,090.43
| Professional | | $1,094.07 | $1,477.26 | $3,090.43 |