- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,041.74 / $5,370.32
| Facility | | $1,174.90 | $2,041.74 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $2,238.72 / $6,025.60
| Facility | | $371.54 | $2,238.72 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,584.89 / $1,995.26
| Professional | | $1,047.13 | $1,584.89 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $457.09 / $489.78
| Facility | | $426.58 | $457.09 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $446.68 / $741.31
| Professional | | $316.23 | $446.68 | $741.31 |