- 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
- $633.82 / $886.77 / $958.13
| Professional | | $633.82 | $886.77 | $958.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.99 / $840.13 / $1,312.84
| Professional | | $606.99 | $840.13 | $1,312.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.13 / $1,098.22 / $1,420.46
| Professional | | $875.13 | $1,098.22 | $1,420.46 |
- 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
- $546.64 / $972.05 / $1,489.26
| Professional | | $546.64 | $972.05 | $1,489.26 |