- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $506.55 / $506.55 / $4,133.45
| Facility | | $506.55 | $506.55 | $4,133.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.55 / $506.55 / $526.80
| Professional | | $506.55 | $506.55 | $526.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.32 / $607.86 / $2,980.95
| Professional | | $540.32 | $607.86 | $2,980.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,097.53 / $1,141.43 / $2,455.71
| Facility | | $1,097.53 | $1,141.43 | $2,455.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $388.41 / $1,520.16 / $5,263.42
| Professional | | $388.41 | $1,520.16 | $5,263.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.71 / $1,372.89 / $1,372.89
| Professional | | $776.71 | $1,372.89 | $1,372.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.67 / $405.24 / $1,027.52
| Professional | | $283.67 | $405.24 | $1,027.52 |