- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $740.13 / $6,907.00 / $19,392.91
| Facility | | $740.13 | $6,907.00 | $19,392.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $725.62 / $740.14 / $855.07
| Professional | | $725.62 | $740.14 | $855.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.25 / $943.09 / $1,281.92
| Professional | | $663.25 | $943.09 | $1,281.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,477.75 / $6,477.75 / $7,092.74
| Facility | | $6,477.75 | $6,477.75 | $7,092.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.80 / $951.80 / $1,662.53
| Professional | | $670.80 | $951.80 | $1,662.53 |