- 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
- $1,673.86 / $2,276.15 / $3,214.81
| Professional | | $1,673.86 | $2,276.15 | $3,214.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,699.61 / $2,352.40 / $4,018.60
| Professional | | $1,699.61 | $2,352.40 | $4,018.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,352.39 / $2,989.26 / $3,909.73
| Professional | | $2,352.39 | $2,989.26 | $3,909.73 |
- 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
- $1,613.36 / $2,368.89 / $3,662.80
| Professional | | $1,613.36 | $2,368.89 | $3,662.80 |