- 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
- $1,426.16 / $1,455.43 / $2,038.77
| Professional | | $1,426.16 | $1,455.43 | $2,038.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,641.93 / $1,931.68 / $3,209.52
| Professional | | $1,641.93 | $1,931.68 | $3,209.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $2,364.65 / $3,429.05
| Professional | | $300.00 | $2,364.65 | $3,429.05 |
- 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
- $1,431.04 / $2,318.19 / $3,575.12
| Professional | | $1,431.04 | $2,318.19 | $3,575.12 |