- 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
- $1,100.02 / $1,221.69 / $1,438.84
| Professional | | $1,100.02 | $1,221.69 | $1,438.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.19 / $1,349.63 / $2,137.87
| Professional | | $1,147.19 | $1,349.63 | $2,137.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,470.00 / $2,268.19
| Professional | | $300.00 | $1,470.00 | $2,268.19 |
- 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
- $1,011.72 / $1,369.38 / $2,377.07
| Professional | | $1,011.72 | $1,369.38 | $2,377.07 |