- 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
- $1,049.06 / $1,135.30 / $1,186.60
| Professional | | $1,049.06 | $1,135.30 | $1,186.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.27 / $1,287.38 / $2,181.71
| Professional | | $1,094.27 | $1,287.38 | $2,181.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.00 / $1,455.27 / $2,121.76
| Professional | | $450.00 | $1,455.27 | $2,121.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,599.00 / $7,228.00 / $12,680.00
| Facility | | $3,599.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.40 / $1,470.72 / $2,135.19
| Professional | | $761.40 | $1,470.72 | $2,135.19 |