- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,897.79
| Facility | | $4,786.30 | $4,786.30 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,905.46 / $2,238.72
| Professional | | $1,318.26 | $1,905.46 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $4,897.79 / $6,025.60
| Facility | | $2,187.76 | $4,897.79 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,089.30 / $2,691.53
| Professional | | $1,862.09 | $2,089.30 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,890.45 / $6,025.60
| Facility | | $1,819.70 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,630.27 / $3,630.78
| Professional | | $1,995.26 | $2,630.27 | $3,630.78 |