- 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
- $987.72 / $1,009.94 / $1,382.75
| Professional | | $987.72 | $1,009.94 | $1,382.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.06 / $1,210.66 / $1,920.00
| Professional | | $1,029.06 | $1,210.66 | $1,920.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $1,318.33 / $2,121.40
| Professional | | $350.00 | $1,318.33 | $2,121.40 |
- 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
- $1,027.90 / $1,404.19 / $1,914.08
| Professional | | $1,027.90 | $1,404.19 | $1,914.08 |