- 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
- $1,002.85 / $1,439.31 / $1,574.66
| Professional | | $1,002.85 | $1,439.31 | $1,574.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.75 / $1,543.24 / $2,607.31
| Professional | | $1,311.75 | $1,543.24 | $2,607.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $1,784.91 / $2,825.52
| Professional | | $500.00 | $1,784.91 | $2,825.52 |
- 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
- $1,213.38 / $1,903.80 / $2,920.89
| Professional | | $1,213.38 | $1,903.80 | $2,920.89 |