- 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
- $1,090.54 / $1,165.56 / $1,334.46
| Professional | | $1,090.54 | $1,165.56 | $1,334.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,131.48 / $1,331.15 / $2,107.63
| Professional | | $1,131.48 | $1,331.15 | $2,107.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.00 / $1,454.66 / $2,267.98
| Professional | | $750.00 | $1,454.66 | $2,267.98 |
- 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
- $991.63 / $1,555.86 / $2,389.27
| Professional | | $991.63 | $1,555.86 | $2,389.27 |