- 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
- $1,120.73 / $1,520.07 / $2,144.30
| Professional | | $1,120.73 | $1,520.07 | $2,144.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.92 / $1,541.75 / $2,697.40
| Professional | | $1,113.92 | $1,541.75 | $2,697.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,541.75 / $2,001.43 / $2,576.23
| Professional | | $1,541.75 | $2,001.43 | $2,576.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,505.00 / $7,819.00 / $19,195.00
| Facility | | $4,505.00 | $7,819.00 | $19,195.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.93 / $1,734.26 / $2,892.28
| Professional | | $1,109.93 | $1,734.26 | $2,892.28 |