- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,706.14 / $3,955.04
| Facility | | $3,706.14 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.36 / $1,216.56 / $1,270.26
| Professional | | $585.36 | $1,216.56 | $1,270.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,100.00 / $1,294.11 / $1,948.93
| Professional | | $1,100.00 | $1,294.11 | $1,948.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.81 / $1,323.96 / $2,281.57
| Professional | | $1,002.81 | $1,323.96 | $2,281.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $4,915.00 / $7,205.00
| Facility | | $1,649.00 | $4,915.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.95 / $1,396.66 / $2,228.04
| Professional | | $975.95 | $1,396.66 | $2,228.04 |