- 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
- $1,630.80 / $2,189.34 / $2,929.22
| Professional | | $1,630.80 | $2,189.34 | $2,929.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.26 / $2,293.79 / $3,812.77
| Professional | | $1,657.26 | $2,293.79 | $3,812.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,293.79 / $2,812.65 / $3,789.76
| Professional | | $2,293.79 | $2,812.65 | $3,789.76 |
- 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
- $1,594.50 / $2,565.06 / $4,580.81
| Professional | | $1,594.50 | $2,565.06 | $4,580.81 |