- 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
- $1,007.50 / $1,107.41 / $1,308.32
| Professional | | $1,007.50 | $1,107.41 | $1,308.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,270.01 / $1,494.13 / $1,884.67
| Professional | | $1,270.01 | $1,494.13 | $1,884.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.00 / $1,693.21 / $2,457.57
| Professional | | $550.00 | $1,693.21 | $2,457.57 |
- 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
- $899.85 / $1,694.23 / $2,612.76
| Professional | | $899.85 | $1,694.23 | $2,612.76 |