- 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 / $1,096.48 / $1,513.56
| Professional | | $1,000.00 | $1,096.48 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $1,698.24 / $2,137.96
| Professional | | $478.63 | $1,698.24 | $2,137.96 |
- 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
- $933.25 / $1,288.25 / $2,041.74
| Professional | | $933.25 | $1,288.25 | $2,041.74 |