- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $672.35 / $2,787.48 / $4,928.72
| Facility | | $672.35 | $2,787.48 | $4,928.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.77 / $751.55 / $1,229.81
| Professional | | $175.77 | $751.55 | $1,229.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.96 / $2,042.64 / $4,873.67
| Facility | | $161.96 | $2,042.64 | $4,873.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.82 / $1,288.80 / $2,595.52
| Professional | | $998.82 | $1,288.80 | $2,595.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.82 / $1,224.35 / $2,290.73
| Professional | | $998.82 | $1,224.35 | $2,290.73 |