- 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
- $1,658.61 / $1,741.81 / $2,306.85
| Professional | | $1,658.61 | $1,741.81 | $2,306.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,729.73 / $2,034.98 / $3,374.38
| Professional | | $1,729.73 | $2,034.98 | $3,374.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.00 / $2,244.77 / $3,595.51
| Professional | | $400.00 | $2,244.77 | $3,595.51 |
- 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
- $1,784.63 / $2,492.29 / $3,401.01
| Professional | | $1,784.63 | $2,492.29 | $3,401.01 |