- 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
- $1,698.24 / $2,238.72 / $2,818.38
| Professional | | $1,698.24 | $2,238.72 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,388.44 / $3,388.44
| Facility | | $1,000.00 | $3,388.44 | $3,388.44 |
- 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 |