- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,505.35 / $1,938.00 / $2,441.83
| Facility | | $1,505.35 | $1,938.00 | $2,441.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.71 / $1,426.00 / $1,505.35
| Professional | | $613.71 | $1,426.00 | $1,505.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.24 / $334.39 / $429.59
| Professional | | $297.24 | $334.39 | $429.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $63.08 / $715.41 / $808.95
| Facility | | $63.08 | $715.41 | $808.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $820.34 / $1,330.77 / $2,091.16
| Professional | | $820.34 | $1,330.77 | $2,091.16 |