- 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
- $1,506.05 / $2,054.12 / $2,324.92
| Professional | | $1,506.05 | $2,054.12 | $2,324.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,529.19 / $2,116.53 / $3,255.96
| Professional | | $1,529.19 | $2,116.53 | $3,255.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.53 / $2,697.95 / $3,517.83
| Professional | | $2,116.53 | $2,697.95 | $3,517.83 |
- 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
- $1,471.44 / $2,229.77 / $3,756.03
| Professional | | $1,471.44 | $2,229.77 | $3,756.03 |