- 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
- $1,471.17 / $1,504.63 / $1,794.85
| Professional | | $1,471.17 | $1,504.63 | $1,794.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.47 / $1,760.55 / $3,144.81
| Professional | | $1,496.47 | $1,760.55 | $3,144.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.00 / $2,163.94 / $2,955.63
| Professional | | $550.00 | $2,163.94 | $2,955.63 |
- 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
- $1,457.43 / $2,010.40 / $3,033.62
| Professional | | $1,457.43 | $2,010.40 | $3,033.62 |