- 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
- $675.45 / $960.54 / $1,061.96
| Professional | | $675.45 | $960.54 | $1,061.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $637.54 / $882.42 / $1,391.03
| Professional | | $637.54 | $882.42 | $1,391.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.19 / $1,179.18 / $1,471.05
| Professional | | $919.19 | $1,179.18 | $1,471.05 |
- 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
- $537.33 / $949.02 / $1,559.01
| Professional | | $537.33 | $949.02 | $1,559.01 |