- 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
- $458.40 / $635.75 / $786.64
| Professional | | $458.40 | $635.75 | $786.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.31 / $611.32 / $1,008.93
| Professional | | $467.31 | $611.32 | $1,008.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $636.90 / $821.81 / $1,078.57
| Professional | | $636.90 | $821.81 | $1,078.57 |
- 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
- $454.74 / $746.96 / $1,144.52
| Professional | | $454.74 | $746.96 | $1,144.52 |