- 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
- $572.76 / $806.07 / $911.04
| Professional | | $572.76 | $806.07 | $911.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.88 / $813.67 / $1,168.72
| Professional | | $587.88 | $813.67 | $1,168.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.57 / $1,040.42 / $1,331.74
| Professional | | $847.57 | $1,040.42 | $1,331.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $568.26 / $923.11 / $1,420.14
| Professional | | $568.26 | $923.11 | $1,420.14 |