- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,149.09 / $1,630.40 / $3,922.16
| Facility | | $1,149.09 | $1,630.40 | $3,922.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.85 / $1,404.18 / $2,020.28
| Professional | | $887.85 | $1,404.18 | $2,020.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,044.63 / $1,490.58 / $3,088.31
| Facility | | $1,044.63 | $1,490.58 | $3,088.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $773.14 / $1,225.80 / $1,852.71
| Professional | | $773.14 | $1,225.80 | $1,852.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $625.83 / $672.62 / $1,182.08
| Facility | | $625.83 | $672.62 | $1,182.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $972.00 / $9,087.00 / $9,087.00
| Professional | | $972.00 | $9,087.00 | $9,087.00 |