- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $509.68 / $509.68 / $4,158.97
| Facility | | $509.68 | $509.68 | $4,158.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $509.68 / $509.68 / $530.05
| Professional | | $509.68 | $509.68 | $530.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $543.66 / $611.61 / $611.61
| Professional | | $543.66 | $611.61 | $611.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,104.30 / $1,148.47 / $2,470.00
| Facility | | $1,104.30 | $1,148.47 | $2,470.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.49 / $976.23 / $5,295.78
| Professional | | $372.49 | $976.23 | $5,295.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.51 / $1,381.36 / $1,381.36
| Professional | | $781.51 | $1,381.36 | $1,381.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.42 / $305.81 / $1,080.52
| Professional | | $285.42 | $305.81 | $1,080.52 |