- 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
- $1,615.26 / $1,791.51 / $2,125.39
| Professional | | $1,615.26 | $1,791.51 | $2,125.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,676.41 / $1,972.25 / $3,145.85
| Professional | | $1,676.41 | $1,972.25 | $3,145.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $2,142.27 / $3,409.02
| Professional | | $350.00 | $2,142.27 | $3,409.02 |
- 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
- $1,677.44 / $2,070.44 / $3,475.33
| Professional | | $1,677.44 | $2,070.44 | $3,475.33 |