- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $604.61 / $2,535.71 / $2,637.02
| Facility | | $604.61 | $2,535.71 | $2,637.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.22 / $318.22 / $1,270.80
| Professional | | $318.22 | $318.22 | $1,270.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.84 / $673.84 / $673.84
| Professional | | $673.84 | $673.84 | $673.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,660.87 / $2,795.03 / $3,354.04
| Professional | | $2,660.87 | $2,795.03 | $3,354.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.22 / $318.22 / $1,270.80
| Facility | | $318.22 | $318.22 | $1,270.80 |