- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,513.56 / $2,454.71
| Facility | | $977.24 | $1,513.56 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $831.76 / $1,174.90
| Professional | | $707.95 | $831.76 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,174.90 / $1,348.96
| Professional | | $660.69 | $1,174.90 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,981.07 / $11,748.98
| Facility | | $1,548.82 | $3,981.07 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $891.25 / $1,412.54
| Professional | | $691.83 | $891.25 | $1,412.54 |