- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,659.59 / $2,344.23
| Facility | | $1,096.48 | $1,659.59 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $912.01 / $1,445.44
| Professional | | $691.83 | $912.01 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,412.54 / $1,905.46
| Professional | | $1,122.02 | $1,412.54 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $954.99 / $1,737.80
| Professional | | $630.96 | $954.99 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,388.44 / $5,011.87
| Facility | | $1,096.48 | $3,388.44 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $851.14 / $1,318.26
| Professional | | $630.96 | $851.14 | $1,318.26 |