- 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
- $1,059.39 / $1,072.65 / $1,447.26
| Professional | | $1,059.39 | $1,072.65 | $1,447.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,135.75 / $1,336.18 / $2,092.32
| Professional | | $1,135.75 | $1,336.18 | $2,092.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,407.34 / $2,174.87
| Professional | | $300.00 | $1,407.34 | $2,174.87 |
- 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
- $949.50 / $1,507.54 / $2,227.90
| Professional | | $949.50 | $1,507.54 | $2,227.90 |