- 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
- $1,381.80 / $1,728.20 / $2,237.38
| Professional | | $1,381.80 | $1,728.20 | $2,237.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,593.00 / $1,874.12 / $2,987.97
| Professional | | $1,593.00 | $1,874.12 | $2,987.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $2,475.94 / $3,741.78
| Professional | | $500.00 | $2,475.94 | $3,741.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $3,630.00 / $7,205.00
| Facility | | $1,649.00 | $3,630.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,264.42 / $2,374.30 / $3,635.23
| Professional | | $1,264.42 | $2,374.30 | $3,635.23 |