- 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
- $1,912.63 / $2,584.42 / $3,666.75
| Professional | | $1,912.63 | $2,584.42 | $3,666.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,940.96 / $2,686.45 / $4,606.03
| Professional | | $1,940.96 | $2,686.45 | $4,606.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,686.45 / $3,390.12 / $4,483.12
| Professional | | $2,686.45 | $3,390.12 | $4,483.12 |
- 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
- $1,727.59 / $3,032.26 / $4,785.34
| Professional | | $1,727.59 | $3,032.26 | $4,785.34 |