- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,698.24 / $2,454.71
| Facility | | $1,148.15 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,122.02 / $1,548.82
| Professional | | $1,000.00 | $1,122.02 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $1,659.59 / $2,187.76
| Professional | | $478.63 | $1,659.59 | $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
- $912.01 / $1,122.02 / $2,089.30
| Professional | | $912.01 | $1,122.02 | $2,089.30 |