- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,548.82 / $2,454.71
| Facility | | $1,023.29 | $1,548.82 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $870.96 / $1,023.29
| Professional | | $691.83 | $870.96 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,288.25 / $1,548.82
| Professional | | $645.65 | $1,288.25 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,071.52 / $2,570.40
| Facility | | $371.54 | $1,071.52 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $933.25 / $1,659.59
| Professional | | $741.31 | $933.25 | $1,659.59 |