- 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 / $1,148.15 / $2,754.23
| Professional | | $1,000.00 | $1,148.15 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,258.93 / $1,949.84
| Professional | | $954.99 | $1,258.93 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $1,318.26 / $2,511.89
| Professional | | $331.13 | $1,318.26 | $2,511.89 |
- 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
- $954.99 / $1,479.11 / $2,570.40
| Professional | | $954.99 | $1,479.11 | $2,570.40 |