- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,698.24 / $2,454.71
| Facility | | $1,318.26 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,148.15 / $1,659.59
| Professional | | $1,000.00 | $1,148.15 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,584.89 / $1,905.46
| Professional | | $933.25 | $1,584.89 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,888.44 / $16,982.44
| Facility | | $2,187.76 | $5,888.44 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $2,041.74
| Professional | | $1,000.00 | $1,288.25 | $2,041.74 |