- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,593.61 / $7,834.63 / $7,834.63
| Facility | | $3,593.61 | $7,834.63 | $7,834.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $599.13 / $2,517.58 / $2,517.58
| Professional | | $599.13 | $2,517.58 | $2,517.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.00 / $1,330.00 / $1,994.00
| Professional | | $1,108.00 | $1,330.00 | $1,994.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $652.55 / $1,000.72 / $1,210.32
| Professional | | $652.55 | $1,000.72 | $1,210.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.00 / $1,235.28 / $1,985.30
| Professional | | $737.00 | $1,235.28 | $1,985.30 |