- 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
- $1,202.97 / $2,281.48 / $2,363.35
| Professional | | $1,202.97 | $2,281.48 | $2,363.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,036.61 / $2,396.01 / $3,588.23
| Professional | | $2,036.61 | $2,396.01 | $3,588.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,864.33 / $2,608.17 / $4,227.55
| Professional | | $1,864.33 | $2,608.17 | $4,227.55 |
- 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
- $2,039.03 / $2,629.72 / $4,130.72
| Professional | | $2,039.03 | $2,629.72 | $4,130.72 |