- 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
- $1,327.08 / $2,430.87 / $2,670.56
| Professional | | $1,327.08 | $2,430.87 | $2,670.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.46 / $2,489.94 / $4,014.63
| Professional | | $2,116.46 | $2,489.94 | $4,014.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,007.94 / $2,871.01 / $4,407.63
| Professional | | $2,007.94 | $2,871.01 | $4,407.63 |
- 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
- $1,831.30 / $2,786.02 / $4,297.70
| Professional | | $1,831.30 | $2,786.02 | $4,297.70 |