- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $577.85 / $2,501.04 / $5,037.75
| Facility | | $577.85 | $2,501.04 | $5,037.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $554.65 / $618.72 / $1,398.39
| Professional | | $554.65 | $618.72 | $1,398.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.54 / $656.71 / $2,319.81
| Professional | | $607.54 | $656.71 | $2,319.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.05 / $648.54 / $2,824.24
| Professional | | $517.05 | $648.54 | $2,824.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.88 / $1,435.37 / $1,435.37
| Professional | | $662.88 | $1,435.37 | $1,435.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.46 / $1,440.62 / $2,035.00
| Professional | | $507.46 | $1,440.62 | $2,035.00 |