- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,435.00 / $1,694.89 / $1,694.89
| Facility | | $1,435.00 | $1,694.89 | $1,694.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,358.93 / $1,398.77 / $1,714.81
| Professional | | $1,358.93 | $1,398.77 | $1,714.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,996.77 / $1,996.77 / $2,510.79
| Professional | | $1,996.77 | $1,996.77 | $2,510.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,372.46 / $1,478.05 / $1,790.43
| Facility | | $1,372.46 | $1,478.05 | $1,790.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.00 / $2,000.00 / $3,900.00
| Professional | | $1,500.00 | $2,000.00 | $3,900.00 |