- 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
- $385.05 / $551.63 / $653.66
| Professional | | $385.05 | $551.63 | $653.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.13 / $604.86 / $1,007.27
| Professional | | $514.13 | $604.86 | $1,007.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $622.36 / $1,081.38
| Professional | | $300.00 | $622.36 | $1,081.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.46 / $562.04 / $1,148.73
| Professional | | $437.46 | $562.04 | $1,148.73 |