- 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
- $1,109.09 / $1,137.50 / $1,541.09
| Professional | | $1,109.09 | $1,137.50 | $1,541.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.72 / $1,354.96 / $2,153.83
| Professional | | $1,151.72 | $1,354.96 | $2,153.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $1,476.02 / $2,327.37
| Professional | | $350.00 | $1,476.02 | $2,327.37 |
- 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
- $1,149.45 / $1,577.16 / $2,426.66
| Professional | | $1,149.45 | $1,577.16 | $2,426.66 |