- 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
- $1,156.70 / $2,093.65 / $2,266.78
| Professional | | $1,156.70 | $2,093.65 | $2,266.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,825.28 / $2,147.39 / $3,350.50
| Professional | | $1,825.28 | $2,147.39 | $3,350.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,731.15 / $2,477.67 / $3,800.36
| Professional | | $1,731.15 | $2,477.67 | $3,800.36 |
- 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
- $1,798.65 / $2,535.64 / $3,884.48
| Professional | | $1,798.65 | $2,535.64 | $3,884.48 |