- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,698.24 / $2,454.71
| Facility | | $1,230.27 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,096.48 / $1,513.56
| Professional | | $1,000.00 | $1,096.48 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,659.59 / $2,089.30
| Professional | | $891.25 | $1,659.59 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $12,302.69
| Facility | | $3,715.35 | $7,762.47 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,041.74
| Professional | | $933.25 | $1,318.26 | $2,041.74 |