- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,073.80
| Facility | | $3,981.07 | $3,981.07 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,995.26 / $5,128.61
| Professional | | $1,621.81 | $1,995.26 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,862.09 / $3,090.30
| Professional | | $1,621.81 | $1,862.09 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,630.27 / $3,715.35
| Professional | | $2,089.30 | $2,630.27 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $18,620.87
| Facility | | $3,715.35 | $7,762.47 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,187.76 / $4,073.80
| Professional | | $1,584.89 | $2,187.76 | $4,073.80 |