- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $650.76 / $2,424.15 / $3,955.04
| Facility | | $650.76 | $2,424.15 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.89 / $581.48 / $711.66
| Professional | | $483.89 | $581.48 | $711.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.09 / $741.56 / $1,000.48
| Professional | | $519.09 | $741.56 | $1,000.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $594.54 / $805.66 / $1,425.86
| Professional | | $594.54 | $805.66 | $1,425.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.79 / $872.45 / $1,529.05
| Professional | | $523.79 | $872.45 | $1,529.05 |