- 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
- $1,010.41 / $1,882.97 / $1,976.95
| Professional | | $1,010.41 | $1,882.97 | $1,976.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,702.40 / $2,002.82 / $2,988.31
| Professional | | $1,702.40 | $2,002.82 | $2,988.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.47 / $2,247.39 / $3,510.57
| Professional | | $1,548.47 | $2,247.39 | $3,510.57 |
- 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
- $1,712.28 / $2,208.91 / $3,423.54
| Professional | | $1,712.28 | $2,208.91 | $3,423.54 |