- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,778.28 / $4,677.35
| Professional | | $1,000.00 | $1,778.28 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,412.54 / $2,454.71
| Professional | | $1,202.26 | $1,412.54 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,187.76 / $3,235.94
| Professional | | $1,513.56 | $2,187.76 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,089.30 / $3,235.94
| Professional | | $1,548.82 | $2,089.30 | $3,235.94 |