- 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
- $467.73 / $637.57 / $815.74
| Professional | | $467.73 | $637.57 | $815.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $499.49 / $628.82 / $1,048.68
| Professional | | $499.49 | $628.82 | $1,048.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $677.28 / $850.65 / $1,116.73
| Professional | | $677.28 | $850.65 | $1,116.73 |
- 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
- $454.11 / $790.71 / $1,189.61
| Professional | | $454.11 | $790.71 | $1,189.61 |