- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,162.28 / $7,762.47
| Facility | | $602.56 | $3,162.28 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $602.56 / $691.83
| Professional | | $524.81 | $602.56 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $676.08 / $1,258.93
| Professional | | $588.84 | $676.08 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,344.23 / $16,218.10
| Facility | | $645.65 | $2,344.23 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $630.96 / $1,513.56
| Professional | | $537.03 | $630.96 | $1,513.56 |