- 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
- $1,243.66 / $2,311.46 / $2,371.59
| Professional | | $1,243.66 | $2,311.46 | $2,371.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,065.90 / $2,430.46 / $3,409.05
| Professional | | $2,065.90 | $2,430.46 | $3,409.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,958.65 / $2,802.81 / $4,301.62
| Professional | | $1,958.65 | $2,802.81 | $4,301.62 |
- 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
- $2,047.14 / $2,721.59 / $4,194.32
| Professional | | $2,047.14 | $2,721.59 | $4,194.32 |