- 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
- $968.85 / $1,025.53 / $1,230.88
| Professional | | $968.85 | $1,025.53 | $1,230.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.76 / $1,193.83 / $1,855.28
| Professional | | $1,014.76 | $1,193.83 | $1,855.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $1,315.24 / $1,970.55
| Professional | | $350.00 | $1,315.24 | $1,970.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $3,630.00 / $7,205.00
| Facility | | $1,649.00 | $3,630.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.57 / $1,365.92 / $2,100.28
| Professional | | $870.57 | $1,365.92 | $2,100.28 |