- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.59 / $756.61 / $912.32
| Professional | | $513.59 | $756.61 | $912.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.41 / $721.68 / $1,249.40
| Professional | | $521.41 | $721.68 | $1,249.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.66 / $989.03 / $1,235.67
| Professional | | $724.66 | $989.03 | $1,235.67 |
- 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
- $530.84 / $856.52 / $1,321.67
| Professional | | $530.84 | $856.52 | $1,321.67 |