- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,819.70 / $2,511.89
| Facility | | $794.33 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $691.83 / $977.24
| Professional | | $602.56 | $691.83 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $954.99 / $1,122.02
| Professional | | $467.74 | $954.99 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $4,677.35 / $9,332.54
| Facility | | $2,187.76 | $4,677.35 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $741.31 / $1,230.27
| Professional | | $602.56 | $741.31 | $1,230.27 |