- 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
- $1,535.28 / $1,625.78 / $1,887.90
| Professional | | $1,535.28 | $1,625.78 | $1,887.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,608.37 / $1,892.20 / $2,794.11
| Professional | | $1,608.37 | $1,892.20 | $2,794.11 |
- 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
- $1,396.41 / $1,947.97 / $3,033.56
| Professional | | $1,396.41 | $1,947.97 | $3,033.56 |