- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $2,570.40 / $2,630.27
| Facility | | $398.11 | $2,570.40 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $398.11 / $478.63
| Professional | | $316.23 | $398.11 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $954.99 / $1,202.26
| Professional | | $724.44 | $954.99 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,089.30 / $2,089.30
| Facility | | $1,000.00 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,698.24 / $1,949.84
| Facility | | $1,445.44 | $1,698.24 | $1,949.84 |