- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $615.47 / $673.70 / $1,280.79
| Facility | | $615.47 | $673.70 | $1,280.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.94 / $615.47 / $649.08
| Professional | | $448.94 | $615.47 | $649.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $490.16 / $552.50 / $1,007.58
| Professional | | $490.16 | $552.50 | $1,007.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,368.04 / $1,368.04 / $2,617.86
| Facility | | $1,368.04 | $1,368.04 | $2,617.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.21 / $715.16 / $1,375.00
| Professional | | $446.21 | $715.16 | $1,375.00 |