- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,263.53 / $1,478.33 / $2,527.06
| Facility | | $1,263.53 | $1,478.33 | $2,527.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $985.55 / $1,478.33 / $1,478.33
| Professional | | $985.55 | $1,478.33 | $1,478.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.67 / $69.98 / $94.15
| Facility | | $57.67 | $69.98 | $94.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $716.30 / $870.00 / $1,026.59
| Professional | | $716.30 | $870.00 | $1,026.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $821.29 / $1,026.60 / $2,734.90
| Facility | | $821.29 | $1,026.60 | $2,734.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.67 / $530.67 / $758.12
| Professional | | $530.67 | $530.67 | $758.12 |