- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,202.26 / $2,818.38
| Facility | | $776.25 | $1,202.26 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $724.44 / $1,348.96
| Professional | | $380.19 | $724.44 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,148.15 / $2,238.72
| Facility | | $912.01 | $1,148.15 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $660.69 / $1,202.26
| Professional | | $380.19 | $660.69 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $346.74 / $489.78
| Facility | | $239.88 | $346.74 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,445.44 / $1,445.44
| Professional | | $1,348.96 | $1,445.44 | $1,445.44 |