- 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
- $1,057.03 / $1,061.42 / $1,469.98
| Professional | | $1,057.03 | $1,061.42 | $1,469.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.58 / $1,304.21 / $2,101.94
| Professional | | $1,108.58 | $1,304.21 | $2,101.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,546.87 / $2,193.94
| Professional | | $300.00 | $1,546.87 | $2,193.94 |
- 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
- $969.26 / $1,520.77 / $2,179.78
| Professional | | $969.26 | $1,520.77 | $2,179.78 |