- 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
- $1,245.83 / $1,689.19 / $2,400.71
| Professional | | $1,245.83 | $1,689.19 | $2,400.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.30 / $1,751.28 / $2,985.44
| Professional | | $1,265.30 | $1,751.28 | $2,985.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.27 / $2,218.96 / $2,852.78
| Professional | | $1,751.27 | $2,218.96 | $2,852.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $2,257.00 / $6,383.00
| Facility | | $1,649.00 | $2,257.00 | $6,383.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,197.30 / $1,928.31 / $3,047.88
| Professional | | $1,197.30 | $1,928.31 | $3,047.88 |