- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $674.35 / $1,131.13 / $2,721.09
| Facility | | $674.35 | $1,131.13 | $2,721.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.22 / $725.12 / $1,359.04
| Professional | | $407.22 | $725.12 | $1,359.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $581.65 / $997.29 / $2,142.59
| Facility | | $581.65 | $997.29 | $2,142.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $366.66 / $636.75 / $1,180.44
| Professional | | $366.66 | $636.75 | $1,180.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.48 / $366.64 / $713.88
| Facility | | $239.48 | $366.64 | $713.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,460.17 / $1,460.17
| Professional | | $1,350.00 | $1,460.17 | $1,460.17 |