- 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
- $1,471.88 / $1,938.03 / $2,418.12
| Professional | | $1,471.88 | $1,938.03 | $2,418.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.61 / $2,071.44 / $3,489.65
| Professional | | $1,496.61 | $2,071.44 | $3,489.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,071.42 / $2,478.69 / $3,406.77
| Professional | | $2,071.42 | $2,478.69 | $3,406.77 |
- 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
- $1,429.82 / $2,306.44 / $3,939.84
| Professional | | $1,429.82 | $2,306.44 | $3,939.84 |