- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $982.33 / $2,389.98 / $5,070.08
| Facility | | $982.33 | $2,389.98 | $5,070.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.96 / $660.27 / $1,720.04
| Professional | | $457.96 | $660.27 | $1,720.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $629.46 / $893.99 / $1,296.28
| Professional | | $629.46 | $893.99 | $1,296.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $823.89 / $1,316.63 / $1,918.16
| Professional | | $823.89 | $1,316.63 | $1,918.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.89 / $1,280.65 / $2,373.73
| Professional | | $720.89 | $1,280.65 | $2,373.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $653.59 / $804.79 / $1,449.76
| Professional | | $653.59 | $804.79 | $1,449.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $499.16 / $598.99 / $880.52
| Professional | | $499.16 | $598.99 | $880.52 |