- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,045.78 / $1,162.20 / $1,162.20
| Facility | | $1,045.78 | $1,162.20 | $1,162.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $411.57 / $1,028.41 / $2,425.73
| Facility | | $411.57 | $1,028.41 | $2,425.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $294.75 / $545.76 / $1,009.31
| Facility | | $294.75 | $545.76 | $1,009.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $442.65 / $442.65 / $442.65
| Professional | | $442.65 | $442.65 | $442.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.02 / $384.88 / $464.94
| Professional | | $302.02 | $384.88 | $464.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $334.10 / $495.62 / $661.34
| Professional | | $334.10 | $495.62 | $661.34 |