- 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
- $1,810.86 / $1,845.34 / $2,457.88
| Professional | | $1,810.86 | $1,845.34 | $2,457.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.66 / $2,206.66 / $3,524.68
| Professional | | $1,875.66 | $2,206.66 | $3,524.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $2,405.39 / $3,756.74
| Professional | | $300.00 | $2,405.39 | $3,756.74 |
- 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
- $1,832.95 / $2,576.37 / $3,962.97
| Professional | | $1,832.95 | $2,576.37 | $3,962.97 |