- 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
- $3,432.38 / $4,846.64 / $6,832.95
| Professional | | $3,432.38 | $4,846.64 | $6,832.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $5,665.41 / $9,338.62
| Professional | | $350.00 | $5,665.41 | $9,338.62 |
- 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
- $4,091.48 / $5,626.91 / $8,570.03
| Professional | | $4,091.48 | $5,626.91 | $8,570.03 |