- 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
- $1,291.75 / $2,440.85 / $2,542.02
| Professional | | $1,291.75 | $2,440.85 | $2,542.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,161.19 / $2,542.58 / $3,858.63
| Professional | | $2,161.19 | $2,542.58 | $3,858.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.74 / $2,896.41 / $4,497.60
| Professional | | $1,995.74 | $2,896.41 | $4,497.60 |
- 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
- $2,184.57 / $2,816.40 / $4,391.75
| Professional | | $2,184.57 | $2,816.40 | $4,391.75 |