- 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
- $1,112.66 / $2,185.73 / $2,319.35
| Professional | | $1,112.66 | $2,185.73 | $2,319.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,753.77 / $2,063.26 / $2,063.26
| Professional | | $1,753.77 | $2,063.26 | $2,063.26 |
- 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
- $2,158.26 / $2,575.23 / $3,889.81
| Professional | | $2,158.26 | $2,575.23 | $3,889.81 |