- 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
- $1,093.55 / $1,788.90 / $1,944.81
| Professional | | $1,093.55 | $1,788.90 | $1,944.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,561.97 / $1,837.61 / $2,864.64
| Professional | | $1,561.97 | $1,837.61 | $2,864.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,477.70 / $2,121.52 / $3,465.42
| Professional | | $1,477.70 | $2,121.52 | $3,465.42 |
- 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
- $1,505.30 / $2,052.14 / $3,169.51
| Professional | | $1,505.30 | $2,052.14 | $3,169.51 |