- 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
- $1,161.91 / $1,186.33 / $1,587.98
| Professional | | $1,161.91 | $1,186.33 | $1,587.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.14 / $1,420.16 / $2,262.32
| Professional | | $1,207.14 | $1,420.16 | $2,262.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $1,544.18 / $2,400.50
| Professional | | $350.00 | $1,544.18 | $2,400.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $4,086.00 / $9,622.00
| Facility | | $3,146.00 | $4,086.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.09 / $1,439.69 / $2,265.67
| Professional | | $1,185.09 | $1,439.69 | $2,265.67 |