- 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
- $1,240.98 / $1,374.87 / $1,486.86
| Professional | | $1,240.98 | $1,374.87 | $1,486.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.61 / $1,550.13 / $2,641.81
| Professional | | $1,317.61 | $1,550.13 | $2,641.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.00 / $1,748.57 / $2,477.13
| Professional | | $450.00 | $1,748.57 | $2,477.13 |
- 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
- $1,157.75 / $1,613.98 / $2,490.71
| Professional | | $1,157.75 | $1,613.98 | $2,490.71 |