- 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
- $1,128.86 / $1,222.40 / $1,452.61
| Professional | | $1,128.86 | $1,222.40 | $1,452.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.50 / $1,347.65 / $2,143.65
| Professional | | $1,145.50 | $1,347.65 | $2,143.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,466.23 / $2,317.71
| Professional | | $300.00 | $1,466.23 | $2,317.71 |
- 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
- $999.58 / $1,568.35 / $2,413.23
| Professional | | $999.58 | $1,568.35 | $2,413.23 |