- 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
- $1,024.77 / $1,948.27 / $2,023.52
| Professional | | $1,024.77 | $1,948.27 | $2,023.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,740.69 / $2,047.87 / $3,074.30
| Professional | | $1,740.69 | $2,047.87 | $3,074.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.59 / $2,291.98 / $3,611.21
| Professional | | $1,590.59 | $2,291.98 | $3,611.21 |
- 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
- $1,743.41 / $2,254.82 / $3,528.69
| Professional | | $1,743.41 | $2,254.82 | $3,528.69 |