- 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 / $1,621.81
| Professional | | $1,000.00 | $1,148.15 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,659.59 / $1,905.46
| Professional | | $933.25 | $1,659.59 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,951.21 / $9,332.54
| Facility | | $1,230.27 | $2,951.21 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,318.26 / $2,041.74
| Professional | | $1,000.00 | $1,318.26 | $2,041.74 |