- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $4,897.79
| Facility | | $1,905.46 | $1,905.46 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,570.40
| Professional | | $1,819.70 | $2,041.74 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,370.32 / $6,165.95
| Professional | | $3,981.07 | $5,370.32 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,890.45
| Professional | | $3,090.30 | $3,090.30 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,041.74 / $4,897.79
| Facility | | $1,621.81 | $2,041.74 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,235.94 / $5,370.32
| Professional | | $1,148.15 | $3,235.94 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,754.23 / $4,570.88
| Professional | | $1,148.15 | $2,754.23 | $4,570.88 |