- 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
- $4,466.84 / $5,623.41 / $12,022.64
| Professional | | $4,466.84 | $5,623.41 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,786.30 / $8,709.64
| Professional | | $3,630.78 | $4,786.30 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $5,128.61 / $10,000.00
| Professional | | $446.68 | $5,128.61 | $10,000.00 |
- 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
- $3,467.37 / $6,025.60 / $9,772.37
| Professional | | $3,467.37 | $6,025.60 | $9,772.37 |