- 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
- $1,267.93 / $2,416.21 / $2,524.78
| Professional | | $1,267.93 | $2,416.21 | $2,524.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,139.27 / $2,516.79 / $3,818.39
| Professional | | $2,139.27 | $2,516.79 | $3,818.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,975.30 / $2,746.28 / $4,451.60
| Professional | | $1,975.30 | $2,746.28 | $4,451.60 |
- 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
- $2,170.16 / $2,787.29 / $4,346.95
| Professional | | $2,170.16 | $2,787.29 | $4,346.95 |