- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,995.26 / $3,981.07
| Facility | | $316.23 | $1,995.26 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $478.63
| Professional | | $316.23 | $316.23 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Facility | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Professional | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $630.96 / $794.33
| Facility | | $426.58 | $630.96 | $794.33 |