- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $671.14 / $1,724.85 / $6,907.00
| Facility | | $671.14 | $1,724.85 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.25 / $671.15 / $779.20
| Professional | | $575.25 | $671.15 | $779.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $582.86 / $705.15 / $1,002.42
| Professional | | $582.86 | $705.15 | $1,002.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,798.17 / $7,410.51 / $9,024.95
| Facility | | $4,798.17 | $7,410.51 | $9,024.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $553.25 / $802.04 / $1,764.49
| Professional | | $553.25 | $802.04 | $1,764.49 |