- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $4,937.68
| Facility | | $3,706.14 | $3,955.04 | $4,937.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.58 / $1,173.05 / $1,566.64
| Professional | | $1,148.58 | $1,173.05 | $1,566.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,193.88 / $1,404.56 / $2,234.98
| Professional | | $1,193.88 | $1,404.56 | $2,234.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $1,527.32 / $2,394.28
| Professional | | $350.00 | $1,527.32 | $2,394.28 |
- 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
- $1,117.05 / $1,635.05 / $2,644.01
| Professional | | $1,117.05 | $1,635.05 | $2,644.01 |