- 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
- $457.09 / $549.54 / $1,412.54
| Professional | | $457.09 | $549.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $549.54 / $891.25
| Professional | | $457.09 | $549.54 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $741.31 / $1,071.52
| Professional | | $501.19 | $741.31 | $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
- $426.58 / $630.96 / $1,096.48
| Professional | | $426.58 | $630.96 | $1,096.48 |