- 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
- $1,153.33 / $1,177.30 / $1,560.39
| Professional | | $1,153.33 | $1,177.30 | $1,560.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,198.35 / $1,409.83 / $2,241.88
| Professional | | $1,198.35 | $1,409.83 | $2,241.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $1,558.70 / $2,366.65
| Professional | | $350.00 | $1,558.70 | $2,366.65 |
- 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
- $1,195.65 / $1,550.16 / $2,231.11
| Professional | | $1,195.65 | $1,550.16 | $2,231.11 |