- 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
- $1,069.10 / $1,991.72 / $2,132.48
| Professional | | $1,069.10 | $1,991.72 | $2,132.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,789.07 / $2,104.79 / $3,242.79
| Professional | | $1,789.07 | $2,104.79 | $3,242.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,643.96 / $2,171.23 / $3,713.62
| Professional | | $1,643.96 | $2,171.23 | $3,713.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $4,915.00 / $7,205.00
| Facility | | $1,649.00 | $4,915.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,791.01 / $1,997.67 / $4,823.93
| Professional | | $1,791.01 | $1,997.67 | $4,823.93 |