- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,235.94 / $4,365.16
| Facility | | $891.25 | $3,235.94 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,122.02 / $1,905.46
| Professional | | $616.60 | $1,122.02 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,778.28 / $5,248.07
| Facility | | $776.25 | $1,778.28 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $676.08 / $1,202.26
| Facility | | $489.78 | $676.08 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Professional | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $1,318.26 / $3,388.44
| Facility | | $467.74 | $1,318.26 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $275.42 / $281.84
| Professional | | $275.42 | $275.42 | $281.84 |