- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,706.14 / $3,955.04
| Facility | | $3,706.14 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,337.40 / $1,680.92 / $1,916.92
| Professional | | $1,337.40 | $1,680.92 | $1,916.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,282.42 / $3,159.07 / $5,295.08
| Professional | | $2,282.42 | $3,159.07 | $5,295.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $2,860.61 / $4,155.82
| Professional | | $250.00 | $2,860.61 | $4,155.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,599.00 / $7,228.00 / $12,680.00
| Facility | | $3,599.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,588.86 / $2,554.35 / $3,933.12
| Professional | | $1,588.86 | $2,554.35 | $3,933.12 |