- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $448.52 / $1,121.30 / $4,840.66
| Facility | | $448.52 | $1,121.30 | $4,840.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.52 / $660.09 / $803.96
| Professional | | $448.52 | $660.09 | $803.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $827.23 / $1,864.98 / $3,877.91
| Facility | | $827.23 | $1,864.98 | $3,877.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.77 / $875.22 / $1,785.66
| Professional | | $476.77 | $875.22 | $1,785.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $592.39 / $888.58 / $1,227.08
| Professional | | $592.39 | $888.58 | $1,227.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $846.27 / $13,785.00 / $13,785.00
| Facility | | $846.27 | $13,785.00 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $351.19 / $507.76 / $867.43
| Professional | | $351.19 | $507.76 | $867.43 |