- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $537.03 / $1,412.54
| Professional | | $436.52 | $537.03 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $549.54 / $891.25
| Professional | | $436.52 | $549.54 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $724.44 / $1,071.52
| Professional | | $501.19 | $724.44 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $616.60 / $1,071.52
| Professional | | $446.68 | $616.60 | $1,071.52 |