- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $359.20 / $1,313.00 / $3,357.87
| Facility | | $359.20 | $1,313.00 | $3,357.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.82 / $1,042.51 / $2,586.77
| Professional | | $161.82 | $1,042.51 | $2,586.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.59 / $289.11 / $2,401.73
| Professional | | $196.59 | $289.11 | $2,401.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.43 / $445.80 / $3,337.23
| Professional | | $316.43 | $445.80 | $3,337.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.00 / $337.00 / $858.00
| Facility | | $130.00 | $337.00 | $858.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,775.12 / $2,225.31 / $3,778.27
| Professional | | $1,775.12 | $2,225.31 | $3,778.27 |