- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $6,456.54
| Facility | | $4,466.84 | $4,466.84 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $446.68 / $1,047.13
| Professional | | $380.19 | $446.68 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $1,479.11
| Professional | | $501.19 | $501.19 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $630.96 / $1,698.24
| Professional | | $354.81 | $630.96 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $575.44 / $1,047.13
| Professional | | $426.58 | $575.44 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $562.34 / $1,096.48
| Professional | | $436.52 | $562.34 | $1,096.48 |