- 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
- $1,104.97 / $2,106.81 / $2,272.36
| Professional | | $1,104.97 | $2,106.81 | $2,272.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,836.39 / $2,160.46 / $3,371.86
| Professional | | $1,836.39 | $2,160.46 | $3,371.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,739.90 / $2,492.71 / $3,823.53
| Professional | | $1,739.90 | $2,492.71 | $3,823.53 |
- 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
- $1,917.35 / $2,155.08 / $3,728.51
| Professional | | $1,917.35 | $2,155.08 | $3,728.51 |