- 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
- $1,404.01 / $1,432.55 / $1,915.26
| Professional | | $1,404.01 | $1,432.55 | $1,915.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.87 / $1,712.79 / $2,727.88
| Professional | | $1,455.87 | $1,712.79 | $2,727.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $1,861.06 / $2,891.09
| Professional | | $350.00 | $1,861.06 | $2,891.09 |
- 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
- $1,271.96 / $1,995.70 / $3,070.26
| Professional | | $1,271.96 | $1,995.70 | $3,070.26 |