- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.48 / $5,826.39 / $6,351.77
| Facility | | $246.48 | $5,826.39 | $6,351.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.48 / $656.82 / $2,619.11
| Professional | | $246.48 | $656.82 | $2,619.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.94 / $626.29 / $5,006.45
| Professional | | $483.94 | $626.29 | $5,006.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.17 / $726.81 / $6,314.48
| Professional | | $383.17 | $726.81 | $6,314.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.48 / $1,994.30 / $4,723.22
| Facility | | $246.48 | $1,994.30 | $4,723.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,006.94 / $3,210.60 / $5,247.34
| Professional | | $2,006.94 | $3,210.60 | $5,247.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,926.36 / $3,658.54 / $5,247.34
| Professional | | $1,926.36 | $3,658.54 | $5,247.34 |