- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,103.62 / $2,327.48 / $3,317.40
| Facility | | $2,103.62 | $2,327.48 | $3,317.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $425.00 / $600.00
| Professional | | $318.75 | $425.00 | $600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $358.96 / $793.74 / $1,013.32
| Facility | | $358.96 | $793.74 | $1,013.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $803.90 / $1,235.09 / $2,171.23
| Facility | | $803.90 | $1,235.09 | $2,171.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,940.81 / $1,940.81 / $1,940.81
| Professional | | $1,940.81 | $1,940.81 | $1,940.81 |