- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,819.70 / $2,511.89
| Facility | | $1,202.26 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,202.26 / $1,862.09
| Professional | | $1,071.52 | $1,202.26 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- 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 / $1,479.11 / $2,187.76
| Professional | | $1,000.00 | $1,479.11 | $2,187.76 |