- 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
- $1,284.88 / $1,302.67 / $1,689.47
| Professional | | $1,284.88 | $1,302.67 | $1,689.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,367.96 / $1,609.36 / $2,487.59
| Professional | | $1,367.96 | $1,609.36 | $2,487.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $1,672.81 / $2,659.01
| Professional | | $350.00 | $1,672.81 | $2,659.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,074.00 / $7,819.00 / $19,195.00
| Facility | | $5,074.00 | $7,819.00 | $19,195.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,169.58 / $1,827.93 / $2,657.25
| Professional | | $1,169.58 | $1,827.93 | $2,657.25 |