- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,073.80
| Facility | | $3,981.07 | $3,981.07 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,230.27 / $1,819.70
| Professional | | $1,000.00 | $1,230.27 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $1,380.38 / $1,621.81
| Professional | | $0.02 | $1,380.38 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,584.89 / $2,511.89
| Professional | | $1,380.38 | $1,584.89 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,244.36 / $13,182.57
| Facility | | $3,235.94 | $7,244.36 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,348.96 / $2,630.27
| Professional | | $933.25 | $1,348.96 | $2,630.27 |