- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,698.24 / $2,454.71
| Facility | | $1,348.96 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,174.90 / $1,621.81
| Professional | | $1,047.13 | $1,174.90 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $1,698.24 / $2,290.87
| Professional | | $478.63 | $1,698.24 | $2,290.87 |
- 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
- $1,000.00 / $1,258.93 / $2,238.72
| Professional | | $1,000.00 | $1,258.93 | $2,238.72 |