- 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
- $1,030.80 / $1,570.07 / $1,947.19
| Professional | | $1,030.80 | $1,570.07 | $1,947.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,715.84 / $2,018.64 / $3,156.74
| Professional | | $1,715.84 | $2,018.64 | $3,156.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.21 / $1,758.59 / $3,586.27
| Professional | | $1,607.21 | $1,758.59 | $3,586.27 |
- 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
- $1,346.02 / $2,268.91 / $3,494.61
| Professional | | $1,346.02 | $2,268.91 | $3,494.61 |