- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,698.24 / $2,454.71
| Facility | | $1,380.38 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,258.93 / $1,479.11
| Professional | | $1,000.00 | $1,258.93 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,737.80 / $2,041.74
| Professional | | $812.83 | $1,737.80 | $2,041.74 |
- 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
- $977.24 / $1,148.15 / $2,089.30
| Professional | | $977.24 | $1,148.15 | $2,089.30 |