- 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
- $1,060.81 / $1,070.75 / $1,474.77
| Professional | | $1,060.81 | $1,070.75 | $1,474.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.44 / $1,316.99 / $2,108.79
| Professional | | $1,119.44 | $1,316.99 | $2,108.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,555.97 / $2,207.86
| Professional | | $300.00 | $1,555.97 | $2,207.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $4,086.00 / $9,622.00
| Facility | | $3,146.00 | $4,086.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,068.59 / $1,530.42 / $2,058.53
| Professional | | $1,068.59 | $1,530.42 | $2,058.53 |