- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,659.59 / $2,454.71
| Facility | | $1,071.52 | $1,659.59 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,000.00 / $1,174.90
| Professional | | $724.44 | $1,000.00 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,698.24 / $2,187.76
| Professional | | $707.95 | $1,698.24 | $2,187.76 |
- 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
- $776.25 / $1,023.29 / $1,905.46
| Professional | | $776.25 | $1,023.29 | $1,905.46 |