- 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
- $1,133.59 / $1,157.08 / $1,564.13
| Professional | | $1,133.59 | $1,157.08 | $1,564.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.22 / $1,384.96 / $2,203.35
| Professional | | $1,177.22 | $1,384.96 | $2,203.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,611.56 / $2,341.36
| Professional | | $300.00 | $1,611.56 | $2,341.36 |
- 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
- $1,168.33 / $1,611.82 / $2,210.36
| Professional | | $1,168.33 | $1,611.82 | $2,210.36 |