- 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
- $446.68 / $549.54 / $1,479.11
| Professional | | $446.68 | $549.54 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $562.34 / $912.01
| Professional | | $446.68 | $562.34 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $758.58 / $1,096.48
| Professional | | $512.86 | $758.58 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $645.65 / $1,122.02
| Professional | | $446.68 | $645.65 | $1,122.02 |