- 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
- $1,081.45 / $1,157.56 / $1,570.71
| Professional | | $1,081.45 | $1,157.56 | $1,570.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,124.10 / $1,322.48 / $2,040.31
| Professional | | $1,124.10 | $1,322.48 | $2,040.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,575.78 / $2,447.96
| Professional | | $300.00 | $1,575.78 | $2,447.96 |
- 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
- $1,120.22 / $1,537.14 / $2,365.19
| Professional | | $1,120.22 | $1,537.14 | $2,365.19 |