- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,202.26 / $1,698.24
| Facility | | $1,122.02 | $1,202.26 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,148.15 / $3,311.31
| Professional | | $933.25 | $1,148.15 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,737.80 / $2,238.72
| Professional | | $724.44 | $1,737.80 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,570.88 / $8,912.51
| Facility | | $2,089.30 | $4,570.88 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,000.00 / $1,949.84
| Professional | | $776.25 | $1,000.00 | $1,949.84 |