- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,949.84 / $1,949.84
| Facility | | $794.33 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $794.33 / $794.33
| Professional | | $323.59 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $489.78 / $630.96
| Professional | | $489.78 | $489.78 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $288.40 / $512.86
| Professional | | $288.40 | $288.40 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,398.83 / $2,818.38
| Facility | | $2,089.30 | $2,398.83 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $436.52 / $436.52
| Professional | | $436.52 | $436.52 | $436.52 |