- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $666.94 / $1,504.11 / $3,126.49
| Facility | | $666.94 | $1,504.11 | $3,126.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.83 / $545.83 / $545.83
| Professional | | $545.83 | $545.83 | $545.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $716.40 / $893.80 / $1,243.13
| Professional | | $716.40 | $893.80 | $1,243.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $682.29 / $682.29 / $8,702.00
| Facility | | $682.29 | $682.29 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.56 / $409.37 / $695.94
| Professional | | $286.56 | $409.37 | $695.94 |