- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,884.03 / $2,884.03
| Facility | | $1,000.00 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,548.13 / $4,365.16
| Professional | | $2,884.03 | $3,548.13 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $2,691.53 / $3,388.44
| Professional | | $229.09 | $2,691.53 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,128.61 / $5,888.44
| Professional | | $3,981.07 | $5,128.61 | $5,888.44 |