- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,290.87 / $5,011.87
| Facility | | $1,096.48 | $2,290.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $588.84 / $1,230.27
| Professional | | $398.11 | $588.84 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $630.96 / $933.25
| Professional | | $407.38 | $630.96 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $724.44 / $1,202.26
| Professional | | $501.19 | $724.44 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $724.44 / $1,445.44
| Professional | | $501.19 | $724.44 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,290.87 / $5,011.87
| Facility | | $1,096.48 | $2,290.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $660.69 / $1,380.38
| Professional | | $436.52 | $660.69 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $630.96 / $1,148.15
| Professional | | $426.58 | $630.96 | $1,148.15 |