- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,089.93 / $2,637.63 / $2,980.32
| Facility | | $1,089.93 | $2,637.63 | $2,980.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.71 / $1,089.93 / $1,212.67
| Professional | | $1,045.71 | $1,089.93 | $1,212.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.50 / $1,375.00 / $2,268.75
| Professional | | $1,237.50 | $1,375.00 | $2,268.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.10 / $3,397.72 / $5,556.59
| Professional | | $1,323.10 | $3,397.72 | $5,556.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.94 / $2,709.81 / $2,709.81
| Professional | | $1,249.94 | $2,709.81 | $2,709.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.46 / $2,811.62 / $3,334.97
| Professional | | $892.46 | $2,811.62 | $3,334.97 |