- 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
- $1,159.63 / $1,536.70 / $1,913.75
| Professional | | $1,159.63 | $1,536.70 | $1,913.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,179.54 / $1,632.58 / $2,679.17
| Professional | | $1,179.54 | $1,632.58 | $2,679.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,632.58 / $1,948.38 / $2,683.49
| Professional | | $1,632.58 | $1,948.38 | $2,683.49 |
- 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
- $1,115.41 / $1,817.13 / $2,867.56
| Professional | | $1,115.41 | $1,817.13 | $2,867.56 |