- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $792.45 / $898.11 / $1,056.58
| Facility | | $792.45 | $898.11 | $1,056.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.78 / $940.29 / $1,231.81
| Professional | | $29.78 | $940.29 | $1,231.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.57 / $1,077.57 / $1,077.57
| Professional | | $1,077.57 | $1,077.57 | $1,077.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.46 / $1,041.46 / $1,306.34
| Professional | | $816.46 | $1,041.46 | $1,306.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.18 / $77.00 / $1,518.89
| Professional | | $34.18 | $77.00 | $1,518.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $953.56 / $1,230.40 / $1,856.07
| Professional | | $953.56 | $1,230.40 | $1,856.07 |