- 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
- $1,516.92 / $1,682.47 / $2,000.83
| Professional | | $1,516.92 | $1,682.47 | $2,000.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,575.35 / $1,853.35 / $2,955.45
| Professional | | $1,575.35 | $1,853.35 | $2,955.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.00 / $2,016.26 / $3,126.40
| Professional | | $400.00 | $2,016.26 | $3,126.40 |
- 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
- $1,504.71 / $1,909.35 / $2,594.11
| Professional | | $1,504.71 | $1,909.35 | $2,594.11 |