- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,288.25 / $2,454.71
| Facility | | $891.25 | $1,288.25 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $794.33 / $933.25
| Professional | | $660.69 | $794.33 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,122.02 / $1,288.25
| Professional | | $724.44 | $1,122.02 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,071.52 / $2,570.40
| Facility | | $371.54 | $1,071.52 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $758.58 / $1,348.96
| Professional | | $602.56 | $758.58 | $1,348.96 |