- 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
- $620.03 / $881.49 / $974.42
| Professional | | $620.03 | $881.49 | $974.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.23 / $810.01 / $1,276.54
| Professional | | $585.23 | $810.01 | $1,276.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $843.76 / $1,082.29 / $1,352.59
| Professional | | $843.76 | $1,082.29 | $1,352.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.55 / $937.57 / $1,440.75
| Professional | | $597.55 | $937.57 | $1,440.75 |