- 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
- $1,656.74 / $2,330.63 / $2,373.92
| Professional | | $1,656.74 | $2,330.63 | $2,373.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,112.67 / $2,485.50 / $4,139.37
| Professional | | $2,112.67 | $2,485.50 | $4,139.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $2,671.28 / $4,450.04
| Professional | | $300.00 | $2,671.28 | $4,450.04 |
- 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
- $1,543.70 / $3,003.59 / $4,634.96
| Professional | | $1,543.70 | $3,003.59 | $4,634.96 |