- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,652.63 / $1,652.63 / $1,744.79
| Facility | | $1,652.63 | $1,652.63 | $1,744.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.38 / $565.00 / $663.88
| Professional | | $494.38 | $565.00 | $663.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.59 / $73.91 / $636.61
| Professional | | $60.59 | $73.91 | $636.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $989.43 / $997.57 / $1,161.30
| Facility | | $989.43 | $997.57 | $1,161.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.24 / $860.24 / $1,030.66
| Professional | | $860.24 | $860.24 | $1,030.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.63 / $423.75 / $967.56
| Professional | | $296.63 | $423.75 | $967.56 |