- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.22 / $327.64 / $1,718.59
| Facility | | $253.22 | $327.64 | $1,718.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.64 / $1,718.59 / $2,881.53
| Professional | | $327.64 | $1,718.59 | $2,881.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $714.66 / $904.98 / $3,770.72
| Professional | | $714.66 | $904.98 | $3,770.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.11 / $1,251.29 / $1,448.34
| Professional | | $357.11 | $1,251.29 | $1,448.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.81 / $942.90 / $1,792.37
| Professional | | $160.81 | $942.90 | $1,792.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $779.52 / $1,214.65 / $2,995.38
| Professional | | $779.52 | $1,214.65 | $2,995.38 |