- 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
- $1,638.57 / $2,063.12 / $2,368.32
| Professional | | $1,638.57 | $2,063.12 | $2,368.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,786.31 / $3,856.48 / $6,510.77
| Professional | | $2,786.31 | $3,856.48 | $6,510.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $3,483.22 / $5,086.12
| Professional | | $250.00 | $3,483.22 | $5,086.12 |
- 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
- $1,971.97 / $2,751.76 / $4,554.99
| Professional | | $1,971.97 | $2,751.76 | $4,554.99 |