- 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
- $1,659.59 / $1,949.84 / $5,011.87
| Professional | | $1,659.59 | $1,949.84 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,819.70 / $3,162.28
| Professional | | $1,621.81 | $1,819.70 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,818.38 / $3,801.89
| Professional | | $2,041.74 | $2,818.38 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,128.31 / $33,113.11
| Facility | | $4,466.84 | $8,128.31 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,290.87 / $3,981.07
| Professional | | $1,584.89 | $2,290.87 | $3,981.07 |