- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,398.83
| Facility | | $1,096.48 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,318.26 / $1,995.26
| Professional | | $977.24 | $1,318.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $1,862.09
| Professional | | $1,047.13 | $1,513.56 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,288.25 / $1,995.26
| Professional | | $812.83 | $1,288.25 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,659.59 / $5,248.07
| Facility | | $660.69 | $1,659.59 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,148.15 / $1,778.28
| Professional | | $831.76 | $1,148.15 | $1,778.28 |