- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,802.25 / $1,802.25 / $2,738.70
| Facility | | $1,802.25 | $1,802.25 | $2,738.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,403.25 / $4,488.00 / $5,474.00
| Professional | | $4,403.25 | $4,488.00 | $5,474.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,534.00 / $1,664.00 / $1,997.00
| Professional | | $1,534.00 | $1,664.00 | $1,997.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.65 / $1,102.83 / $1,525.28
| Professional | | $814.65 | $1,102.83 | $1,525.28 |
- 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
- $913.00 / $1,536.32 / $2,482.92
| Professional | | $913.00 | $1,536.32 | $2,482.92 |