- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $800.25 / $842.82 / $1,607.61
| Facility | | $800.25 | $842.82 | $1,607.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,282.03 / $2,177.62 / $5,960.08
| Professional | | $1,282.03 | $2,177.62 | $5,960.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $705.45 / $1,727.67 / $13,769.44
| Facility | | $705.45 | $1,727.67 | $13,769.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.56 / $1,438.82 / $2,654.20
| Professional | | $420.56 | $1,438.82 | $2,654.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.50 / $2,926.21 / $5,340.02
| Professional | | $1,437.50 | $2,926.21 | $5,340.02 |