- 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
- $1,340.53 / $1,486.51 / $1,766.39
| Professional | | $1,340.53 | $1,486.51 | $1,766.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.56 / $1,640.66 / $2,608.35
| Professional | | $1,394.56 | $1,640.66 | $2,608.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,783.87 / $2,758.90
| Professional | | $300.00 | $1,783.87 | $2,758.90 |
- 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
- $900.31 / $1,909.80 / $2,938.36
| Professional | | $900.31 | $1,909.80 | $2,938.36 |