- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $5,496.04
| Facility | | $3,706.14 | $3,955.04 | $5,496.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.18 / $1,248.63 / $1,679.81
| Professional | | $1,224.18 | $1,248.63 | $1,679.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.30 / $1,495.65 / $2,378.58
| Professional | | $1,271.30 | $1,495.65 | $2,378.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $1,627.40 / $2,510.48
| Professional | | $350.00 | $1,627.40 | $2,510.48 |
- 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
- $1,254.40 / $1,683.37 / $2,387.40
| Professional | | $1,254.40 | $1,683.37 | $2,387.40 |