- 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
- $1,150.69 / $1,166.25 / $1,600.36
| Professional | | $1,150.69 | $1,166.25 | $1,600.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,218.55 / $1,433.59 / $2,291.37
| Professional | | $1,218.55 | $1,433.59 | $2,291.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,725.20 / $2,588.65
| Professional | | $150.00 | $1,725.20 | $2,588.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $3,447.00 / $7,350.00
| Facility | | $2,654.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,208.46 / $1,553.28 / $2,398.46
| Professional | | $1,208.46 | $1,553.28 | $2,398.46 |