- 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
- $1,108.78 / $1,131.58 / $1,592.79
| Professional | | $1,108.78 | $1,131.58 | $1,592.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.02 / $1,354.14 / $2,400.44
| Professional | | $1,151.02 | $1,354.14 | $2,400.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,472.95 / $2,280.56
| Professional | | $300.00 | $1,472.95 | $2,280.56 |
- 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
- $1,148.36 / $1,576.16 / $2,425.13
| Professional | | $1,148.36 | $1,576.16 | $2,425.13 |