- 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
- $1,271.96 / $2,063.56 / $2,423.44
| Professional | | $1,271.96 | $2,063.56 | $2,423.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,139.46 / $2,517.01 / $4,060.83
| Professional | | $2,139.46 | $2,517.01 | $4,060.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,982.07 / $2,577.28 / $4,456.60
| Professional | | $1,982.07 | $2,577.28 | $4,456.60 |
- 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
- $1,875.46 / $2,795.37 / $4,350.80
| Professional | | $1,875.46 | $2,795.37 | $4,350.80 |