- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,288.25 / $2,454.71
| Facility | | $812.83 | $1,288.25 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $724.44 / $1,096.48
| Professional | | $616.60 | $724.44 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $537.03 / $562.34
| Facility | | $512.86 | $537.03 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $933.25 / $1,202.26
| Professional | | $616.60 | $933.25 | $1,202.26 |
- 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
- $616.60 / $794.33 / $1,230.27
| Professional | | $616.60 | $794.33 | $1,230.27 |