- 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
- $1,024.18 / $1,915.69 / $2,031.27
| Professional | | $1,024.18 | $1,915.69 | $2,031.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,717.05 / $2,020.06 / $3,095.07
| Professional | | $1,717.05 | $2,020.06 | $3,095.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,578.41 / $2,138.01 / $3,567.94
| Professional | | $1,578.41 | $2,138.01 | $3,567.94 |
- 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
- $1,748.97 / $2,230.61 / $3,481.97
| Professional | | $1,748.97 | $2,230.61 | $3,481.97 |