- 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
- $1,246.13 / $1,343.09 / $1,462.18
| Professional | | $1,246.13 | $1,343.09 | $1,462.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,297.75 / $1,526.76 / $2,587.77
| Professional | | $1,297.75 | $1,526.76 | $2,587.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.00 / $1,726.65 / $2,512.15
| Professional | | $450.00 | $1,726.65 | $2,512.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.00 / $2,384.00 / $5,510.00
| Facility | | $1,395.00 | $2,384.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.31 / $1,271.08 / $2,684.37
| Professional | | $1,083.31 | $1,271.08 | $2,684.37 |