- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,819.70 / $2,511.89
| Facility | | $602.56 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $524.81 / $741.31
| Professional | | $467.74 | $524.81 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $831.76 / $1,023.29
| Professional | | $630.96 | $831.76 | $1,023.29 |
- 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
- $436.52 / $602.56 / $1,000.00
| Professional | | $436.52 | $602.56 | $1,000.00 |