- 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
- $1,261.69 / $1,284.14 / $1,714.63
| Professional | | $1,261.69 | $1,284.14 | $1,714.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,315.44 / $1,547.58 / $2,441.65
| Professional | | $1,315.44 | $1,547.58 | $2,441.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,687.05 / $2,586.40
| Professional | | $300.00 | $1,687.05 | $2,586.40 |
- 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
- $1,281.14 / $1,789.82 / $2,754.67
| Professional | | $1,281.14 | $1,789.82 | $2,754.67 |