- 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
- $1,038.33 / $1,357.20 / $1,533.92
| Professional | | $1,038.33 | $1,357.20 | $1,533.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,481.22 / $1,742.61 / $2,473.44
| Professional | | $1,481.22 | $1,742.61 | $2,473.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $2,084.79 / $3,059.06
| Professional | | $300.00 | $2,084.79 | $3,059.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $4,915.00 / $7,205.00
| Facility | | $1,649.00 | $4,915.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.79 / $1,718.68 / $2,720.68
| Professional | | $1,172.79 | $1,718.68 | $2,720.68 |