- 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
- $1,158.63 / $2,021.91 / $2,272.56
| Professional | | $1,158.63 | $2,021.91 | $2,272.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,765.25 / $2,076.76 / $3,451.09
| Professional | | $1,765.25 | $2,076.76 | $3,451.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,671.61 / $2,396.59 / $3,750.39
| Professional | | $1,671.61 | $2,396.59 | $3,750.39 |
- 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
- $1,921.10 / $2,321.54 / $3,580.49
| Professional | | $1,921.10 | $2,321.54 | $3,580.49 |