- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,096.48 / $2,041.74
| Facility | | $794.33 | $1,096.48 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $812.83 / $1,288.25
| Professional | | $707.95 | $812.83 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,230.27 / $1,412.54
| Professional | | $776.25 | $1,230.27 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,570.88 / $8,912.51
| Facility | | $2,089.30 | $4,570.88 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $954.99 / $1,479.11
| Professional | | $741.31 | $954.99 | $1,479.11 |