- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,348.96 / $2,454.71
| Facility | | $912.01 | $1,348.96 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $794.33 / $1,122.02
| Professional | | $691.83 | $794.33 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,122.02 / $1,318.26
| Professional | | $645.65 | $1,122.02 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,888.44 / $14,454.40
| Facility | | $2,187.76 | $5,888.44 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $891.25 / $1,412.54
| Professional | | $691.83 | $891.25 | $1,412.54 |