- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $304.19 / $4,705.80 / $6,907.00
| Facility | | $304.19 | $4,705.80 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.44 / $304.20 / $322.23
| Professional | | $299.44 | $304.20 | $322.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.58 / $380.01 / $526.88
| Professional | | $272.58 | $380.01 | $526.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,906.02 / $5,113.18 / $5,644.71
| Facility | | $1,906.02 | $5,113.18 | $5,644.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.99 / $383.44 / $687.57
| Professional | | $301.99 | $383.44 | $687.57 |