- 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
- $1,023.29 / $1,288.25 / $2,089.30
| Professional | | $1,023.29 | $1,288.25 | $2,089.30 |
- 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
- $1,288.25 / $2,041.74 / $2,754.23
| Professional | | $1,288.25 | $2,041.74 | $2,754.23 |
- 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
- $1,479.11 / $2,511.89 / $3,235.94
| Professional | | $1,479.11 | $2,511.89 | $3,235.94 |