- 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
- $1,154.46 / $2,201.76 / $2,283.23
| Professional | | $1,154.46 | $2,201.76 | $2,283.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.31 / $2,307.42 / $3,423.24
| Professional | | $1,961.31 | $2,307.42 | $3,423.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.86 / $2,554.82 / $4,073.27
| Professional | | $1,798.86 | $2,554.82 | $4,073.27 |
- 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
- $1,979.60 / $2,549.48 / $3,979.36
| Professional | | $1,979.60 | $2,549.48 | $3,979.36 |