- 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
- $1,668.36 / $1,816.38 / $1,975.42
| Professional | | $1,668.36 | $1,816.38 | $1,975.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,735.86 / $2,042.19 / $3,480.18
| Professional | | $1,735.86 | $2,042.19 | $3,480.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.00 / $2,301.85 / $3,409.97
| Professional | | $550.00 | $2,301.85 | $3,409.97 |
- 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
- $1,496.50 / $2,348.01 / $4,551.87
| Professional | | $1,496.50 | $2,348.01 | $4,551.87 |