- 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
- $1,000.65 / $1,903.16 / $1,985.21
| Professional | | $1,000.65 | $1,903.16 | $1,985.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,691.53 / $1,990.04 / $3,000.25
| Professional | | $1,691.53 | $1,990.04 | $3,000.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.48 / $2,053.28 / $3,514.55
| Professional | | $1,556.48 | $2,053.28 | $3,514.55 |
- 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
- $1,607.43 / $2,197.63 / $3,432.66
| Professional | | $1,607.43 | $2,197.63 | $3,432.66 |