- 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
- $1,621.70 / $1,761.28 / $1,925.20
| Professional | | $1,621.70 | $1,761.28 | $1,925.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,680.33 / $1,976.86 / $3,386.76
| Professional | | $1,680.33 | $1,976.86 | $3,386.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $2,237.42 / $3,316.51
| Professional | | $500.00 | $2,237.42 | $3,316.51 |
- 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
- $1,453.01 / $2,279.77 / $3,511.46
| Professional | | $1,453.01 | $2,279.77 | $3,511.46 |