- 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
- $872.27 / $917.13 / $1,075.46
| Professional | | $872.27 | $917.13 | $1,075.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.20 / $1,235.53 / $1,813.45
| Professional | | $1,050.20 | $1,235.53 | $1,813.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $1,201.46 / $1,987.87
| Professional | | $350.00 | $1,201.46 | $1,987.87 |
- 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
- $872.07 / $1,183.59 / $2,171.28
| Professional | | $872.07 | $1,183.59 | $2,171.28 |