- 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
- $1,006.04 / $1,769.45 / $1,898.65
| Professional | | $1,006.04 | $1,769.45 | $1,898.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,687.36 / $1,985.13 / $3,013.82
| Professional | | $1,687.36 | $1,985.13 | $3,013.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,552.91 / $2,228.07 / $3,508.96
| Professional | | $1,552.91 | $2,228.07 | $3,508.96 |
- 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
- $1,602.02 / $2,190.51 / $3,427.50
| Professional | | $1,602.02 | $2,190.51 | $3,427.50 |