- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,435.89 / $3,435.89 / $3,435.89
| Facility | | $3,435.89 | $3,435.89 | $3,435.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.42 / $840.10 / $1,360.72
| Professional | | $794.42 | $840.10 | $1,360.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.55 / $1,079.55 / $2,696.01
| Professional | | $1,079.55 | $1,079.55 | $2,696.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.00 / $1,162.60 / $3,128.77
| Professional | | $750.00 | $1,162.60 | $3,128.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.16 / $1,965.07 / $2,320.54
| Professional | | $935.16 | $1,965.07 | $2,320.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $692.73 / $950.01 / $2,568.96
| Professional | | $692.73 | $950.01 | $2,568.96 |