- 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
- $1,413.61 / $1,418.38 / $1,833.45
| Professional | | $1,413.61 | $1,418.38 | $1,833.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,495.96 / $1,759.95 / $2,620.71
| Professional | | $1,495.96 | $1,759.95 | $2,620.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,972.09 / $2,912.38
| Professional | | $300.00 | $1,972.09 | $2,912.38 |
- 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
- $1,318.50 / $1,803.77 / $2,914.48
| Professional | | $1,318.50 | $1,803.77 | $2,914.48 |