- 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
- $1,020.45 / $1,653.34 / $1,766.92
| Professional | | $1,020.45 | $1,653.34 | $1,766.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.15 / $1,703.71 / $2,652.31
| Professional | | $1,448.15 | $1,703.71 | $2,652.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,363.87 / $1,611.68 / $3,054.96
| Professional | | $1,363.87 | $1,611.68 | $3,054.96 |
- 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
- $1,238.01 / $1,896.18 / $2,934.32
| Professional | | $1,238.01 | $1,896.18 | $2,934.32 |