- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,819.70 / $2,511.89
| Facility | | $977.24 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $912.01 / $1,096.48
| Professional | | $691.83 | $912.01 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,288.25 / $1,479.11
| Professional | | $602.56 | $1,288.25 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,754.23 / $5,495.41
| Facility | | $1,230.27 | $2,754.23 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $851.14 / $1,548.82
| Professional | | $691.83 | $851.14 | $1,548.82 |