- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,258.93 / $2,951.21
| Professional | | $1,000.00 | $1,258.93 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,071.52 / $1,862.09
| Professional | | $794.33 | $1,071.52 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,380.38 / $2,187.76
| Professional | | $181.97 | $1,380.38 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,041.74
| Professional | | $933.25 | $1,318.26 | $2,041.74 |