- 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
- $1,071.52 / $1,380.38 / $3,388.44
| Professional | | $1,071.52 | $1,380.38 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,148.15 / $1,905.46
| Professional | | $870.96 | $1,148.15 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $1,479.11 / $2,344.23
| Professional | | $208.93 | $1,479.11 | $2,344.23 |
- 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
- $1,000.00 / $1,412.54 / $2,137.96
| Professional | | $1,000.00 | $1,412.54 | $2,137.96 |