- 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
- $287.56 / $287.56 / $287.56
| Professional | | $287.56 | $287.56 | $287.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $879.96 / $1,576.44 / $1,986.10
| Facility | | $879.96 | $1,576.44 | $1,986.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.00 / $2,445.00 / $4,602.00
| Facility | | $1,388.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,136.73 / $2,136.73 / $2,136.73
| Professional | | $2,136.73 | $2,136.73 | $2,136.73 |