- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $903.64 / $1,515.74 / $3,646.31
| Facility | | $903.64 | $1,515.74 | $3,646.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.34 / $665.60 / $923.46
| Professional | | $529.34 | $665.60 | $923.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $828.40 / $1,385.75 / $2,871.11
| Facility | | $828.40 | $1,385.75 | $2,871.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.10 / $524.10 / $828.40
| Professional | | $524.10 | $524.10 | $828.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,221.85 / $1,221.85 / $1,221.85
| Facility | | $1,221.85 | $1,221.85 | $1,221.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,010.38 / $2,010.38 / $2,010.38
| Professional | | $2,010.38 | $2,010.38 | $2,010.38 |