- 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 / $3,467.37
| Professional | | $1,071.52 | $1,380.38 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,148.15 / $1,905.46
| Professional | | $851.14 | $1,148.15 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,445.44 / $2,344.23
| Professional | | $181.97 | $1,445.44 | $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 / $1,380.38 / $2,398.83
| Professional | | $1,000.00 | $1,380.38 | $2,398.83 |