- 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
- $1,896.84 / $2,686.26 / $2,728.88
| Professional | | $1,896.84 | $2,686.26 | $2,728.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,421.82 / $2,849.20 / $4,752.83
| Professional | | $2,421.82 | $2,849.20 | $4,752.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $3,067.81 / $5,109.25
| Professional | | $500.00 | $3,067.81 | $5,109.25 |
- 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
- $2,175.35 / $2,949.53 / $4,142.16
| Professional | | $2,175.35 | $2,949.53 | $4,142.16 |