- 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
- $1,077.57 / $1,536.01 / $1,629.60
| Professional | | $1,077.57 | $1,536.01 | $1,629.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,418.01 / $9,419.70 / $11,134.41
| Facility | | $8,418.01 | $9,419.70 | $11,134.41 |
- 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
- $1,560.71 / $1,957.53 / $4,001.53
| Professional | | $1,560.71 | $1,957.53 | $4,001.53 |