- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,819.70 / $2,511.89
| Facility | | $616.60 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $758.58 / $1,023.29
| Professional | | $489.78 | $758.58 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $562.34
| Facility | | $512.86 | $512.86 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,023.29 / $1,479.11
| Professional | | $588.84 | $1,023.29 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $758.58 / $2,570.40
| Facility | | $371.54 | $758.58 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $912.01 / $1,778.28
| Professional | | $588.84 | $912.01 | $1,778.28 |