- 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
- $1,122.34 / $1,135.11 / $1,440.80
| Professional | | $1,122.34 | $1,135.11 | $1,440.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.10 / $1,324.84 / $2,065.42
| Professional | | $1,126.10 | $1,324.84 | $2,065.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,451.90 / $2,196.64
| Professional | | $300.00 | $1,451.90 | $2,196.64 |
- 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
- $1,025.40 / $1,522.63 / $2,343.13
| Professional | | $1,025.40 | $1,522.63 | $2,343.13 |