- 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
- $1,439.60 / $1,677.54 / $2,771.21
| Professional | | $1,439.60 | $1,677.54 | $2,771.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,470.46 / $2,906.44 / $4,220.08
| Professional | | $2,470.46 | $2,906.44 | $4,220.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.49 / $3,459.21 / $6,406.33
| Professional | | $1,857.49 | $3,459.21 | $6,406.33 |
- 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
- $1,453.97 / $1,594.70 / $4,884.06
| Professional | | $1,453.97 | $1,594.70 | $4,884.06 |