- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,490.60 / $1,872.66 / $3,726.23
| Facility | | $1,490.60 | $1,872.66 | $3,726.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $636.59 / $636.59 / $636.59
| Professional | | $636.59 | $636.59 | $636.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.58 / $1,014.67 / $1,715.71
| Professional | | $528.58 | $1,014.67 | $1,715.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $600.55 / $600.55 / $636.59
| Facility | | $600.55 | $600.55 | $636.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.10 / $541.10 / $636.59
| Professional | | $541.10 | $541.10 | $636.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $579.29 / $636.59 / $1,031.77
| Professional | | $579.29 | $636.59 | $1,031.77 |