- 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
- $1,159.06 / $1,183.35 / $1,557.31
| Professional | | $1,159.06 | $1,183.35 | $1,557.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,204.66 / $1,417.25 / $2,254.28
| Professional | | $1,204.66 | $1,417.25 | $2,254.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,541.03 / $2,424.73
| Professional | | $300.00 | $1,541.03 | $2,424.73 |
- 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
- $1,162.04 / $1,649.36 / $2,537.67
| Professional | | $1,162.04 | $1,649.36 | $2,537.67 |