- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,706.14 / $3,955.04
| Facility | | $3,706.14 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,259.07 / $1,774.32 / $2,086.58
| Professional | | $1,259.07 | $1,774.32 | $2,086.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,193.59 / $1,652.05 / $2,664.62
| Professional | | $1,193.59 | $1,652.05 | $2,664.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,720.88 / $2,180.05 / $2,867.30
| Professional | | $1,720.88 | $2,180.05 | $2,867.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.40 / $1,987.51 / $3,043.19
| Professional | | $1,203.40 | $1,987.51 | $3,043.19 |