- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.26 / $3,706.14 / $4,026.21
| Facility | | $3,438.26 | $3,706.14 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $443.27 / $629.22 / $664.70
| Professional | | $443.27 | $629.22 | $664.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $605.29 / $712.10 / $1,086.45
| Professional | | $605.29 | $712.10 | $1,086.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $468.33 / $707.54 / $1,263.08
| Professional | | $468.33 | $707.54 | $1,263.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,417.00 / $4,915.00
| Facility | | $540.00 | $1,417.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $427.79 / $613.52 / $936.21
| Professional | | $427.79 | $613.52 | $936.21 |