- 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
- $1,404.80 / $1,895.13 / $2,690.37
| Professional | | $1,404.80 | $1,895.13 | $2,690.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.04 / $1,975.14 / $3,361.37
| Professional | | $1,427.04 | $1,975.14 | $3,361.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,975.14 / $2,489.64 / $3,272.24
| Professional | | $1,975.14 | $2,489.64 | $3,272.24 |
- 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
- $1,417.16 / $2,202.54 / $3,494.60
| Professional | | $1,417.16 | $2,202.54 | $3,494.60 |