- 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
- $1,506.59 / $1,511.82 / $1,987.48
| Professional | | $1,506.59 | $1,511.82 | $1,987.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,601.44 / $1,884.05 / $2,901.91
| Professional | | $1,601.44 | $1,884.05 | $2,901.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $2,020.87 / $3,102.80
| Professional | | $350.00 | $2,020.87 | $3,102.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,074.00 / $6,917.00 / $19,195.00
| Facility | | $5,074.00 | $6,917.00 | $19,195.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,415.33 / $2,122.13 / $3,110.00
| Professional | | $1,415.33 | $2,122.13 | $3,110.00 |