- 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
- $1,012.45 / $1,648.02 / $1,780.16
| Professional | | $1,012.45 | $1,648.02 | $1,780.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,441.19 / $1,695.52 / $2,639.09
| Professional | | $1,441.19 | $1,695.52 | $2,639.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.95 / $1,958.94 / $3,188.71
| Professional | | $1,360.95 | $1,958.94 | $3,188.71 |
- 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
- $1,386.56 / $1,855.44 / $2,923.03
| Professional | | $1,386.56 | $1,855.44 | $2,923.03 |