- 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
- $1,092.91 / $2,040.93 / $2,175.71
| Professional | | $1,092.91 | $2,040.93 | $2,175.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,831.31 / $2,154.48 / $3,298.48
| Professional | | $1,831.31 | $2,154.48 | $3,298.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.47 / $2,287.87 / $3,803.01
| Professional | | $1,681.47 | $2,287.87 | $3,803.01 |
- 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
- $1,874.25 / $2,062.63 / $3,646.34
| Professional | | $1,874.25 | $2,062.63 | $3,646.34 |