- 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
- $1,641.32 / $2,216.04 / $3,110.91
| Professional | | $1,641.32 | $2,216.04 | $3,110.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.15 / $2,306.09 / $3,944.36
| Professional | | $1,666.15 | $2,306.09 | $3,944.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,306.09 / $2,908.10 / $3,838.58
| Professional | | $2,306.09 | $2,908.10 | $3,838.58 |
- 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
- $1,661.83 / $2,331.17 / $4,098.01
| Professional | | $1,661.83 | $2,331.17 | $4,098.01 |