- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.41 / $656.78 / $1,912.53
| Facility | | $525.41 | $656.78 | $1,912.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.41 / $525.41 / $595.48
| Professional | | $525.41 | $525.41 | $595.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.29 / $924.74 / $1,380.10
| Professional | | $364.29 | $924.74 | $1,380.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,218.97 / $3,327.66 / $3,327.66
| Facility | | $1,218.97 | $3,327.66 | $3,327.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,488.79 / $3,488.79 / $5,254.20
| Professional | | $3,488.79 | $3,488.79 | $5,254.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.24 / $420.34 / $700.56
| Professional | | $294.24 | $420.34 | $700.56 |