- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,819.70 / $3,019.95
| Facility | | $1,096.48 | $1,819.70 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $954.99 / $3,235.94
| Professional | | $831.76 | $954.99 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,318.26 / $1,548.82
| Professional | | $776.25 | $1,318.26 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $4,677.35 / $9,332.54
| Facility | | $2,187.76 | $4,677.35 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,047.13 / $1,698.24
| Professional | | $831.76 | $1,047.13 | $1,698.24 |