- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,786.30
| Facility | | $3,981.07 | $3,981.07 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,230.27 / $3,235.94
| Professional | | $977.24 | $1,230.27 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,348.96 / $1,778.28
| Professional | | $1,023.29 | $1,348.96 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,905.46 / $2,570.40
| Professional | | $1,479.11 | $1,905.46 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,513.56 / $2,630.27
| Professional | | $1,000.00 | $1,513.56 | $2,630.27 |