- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,698.24 / $2,454.71
| Facility | | $1,071.52 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,000.00 / $1,412.54
| Professional | | $870.96 | $1,000.00 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,412.54 / $1,659.59
| Professional | | $812.83 | $1,412.54 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,754.40 / $12,022.64
| Facility | | $3,388.44 | $5,754.40 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,122.02 / $1,778.28
| Professional | | $851.14 | $1,122.02 | $1,778.28 |