- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $1,543.03 / $3,955.04
| Facility | | $1,518.41 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.61 / $653.04 / $668.58
| Professional | | $453.61 | $653.04 | $668.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.13 / $713.09 / $1,119.08
| Professional | | $606.13 | $713.09 | $1,119.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.80 / $713.92 / $1,277.86
| Professional | | $482.80 | $713.92 | $1,277.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $4,628.00 / $7,350.00
| Facility | | $2,654.00 | $4,628.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.96 / $592.42 / $907.02
| Professional | | $422.96 | $592.42 | $907.02 |