- 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
- $1,035.23 / $1,918.28 / $1,957.00
| Professional | | $1,035.23 | $1,918.28 | $1,957.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,717.62 / $2,020.73 / $3,062.68
| Professional | | $1,717.62 | $2,020.73 | $3,062.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,581.92 / $2,181.29 / $3,570.29
| Professional | | $1,581.92 | $2,181.29 | $3,570.29 |
- 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
- $1,424.10 / $2,234.66 / $3,427.01
| Professional | | $1,424.10 | $2,234.66 | $3,427.01 |