- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,995.26 / $4,786.30
| Facility | | $891.25 | $1,995.26 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $346.74 / $1,905.46
| Professional | | $120.23 | $346.74 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $660.69 / $1,513.56
| Professional | | $354.81 | $660.69 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $354.81 / $812.83
| Professional | | $147.91 | $354.81 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,288.25 / $5,370.32
| Facility | | $794.33 | $1,288.25 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $426.58 / $851.14
| Professional | | $173.78 | $426.58 | $851.14 |