- 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
- $1,203.58 / $2,193.48 / $2,296.80
| Professional | | $1,203.58 | $2,193.48 | $2,296.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.02 / $2,404.73 / $3,815.96
| Professional | | $2,044.02 | $2,404.73 | $3,815.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.46 / $2,731.29 / $4,246.51
| Professional | | $1,877.46 | $2,731.29 | $4,246.51 |
- 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
- $1,949.35 / $2,647.20 / $4,148.45
| Professional | | $1,949.35 | $2,647.20 | $4,148.45 |