- 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
- $1,079.73 / $1,969.42 / $2,172.86
| Professional | | $1,079.73 | $1,969.42 | $2,172.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.24 / $2,021.46 / $3,241.57
| Professional | | $1,718.24 | $2,021.46 | $3,241.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.67 / $2,332.61 / $3,575.46
| Professional | | $1,626.67 | $2,332.61 | $3,575.46 |
- 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
- $1,788.70 / $2,260.03 / $3,486.55
| Professional | | $1,788.70 | $2,260.03 | $3,486.55 |