- 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
- $654.88 / $924.50 / $1,079.23
| Professional | | $654.88 | $924.50 | $1,079.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $629.44 / $871.20 / $1,377.41
| Professional | | $629.44 | $871.20 | $1,377.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.50 / $1,154.64 / $1,487.83
| Professional | | $907.50 | $1,154.64 | $1,487.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,299.00 / $4,374.00 / $9,622.00
| Facility | | $2,299.00 | $4,374.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.31 / $1,016.20 / $1,562.51
| Professional | | $657.31 | $1,016.20 | $1,562.51 |