- 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
- $655.45 / $856.91 / $1,225.48
| Professional | | $655.45 | $856.91 | $1,225.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $715.35 / $868.64 / $1,563.61
| Professional | | $715.35 | $868.64 | $1,563.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.92 / $1,276.53 / $1,680.80
| Professional | | $810.92 | $1,276.53 | $1,680.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,806.00 / $3,465.00 / $5,510.00
| Facility | | $1,806.00 | $3,465.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $619.69 / $1,182.33 / $1,799.65
| Professional | | $619.69 | $1,182.33 | $1,799.65 |