- 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
- $1,087.45 / $1,376.19 / $1,883.24
| Professional | | $1,087.45 | $1,376.19 | $1,883.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.10 / $1,539.25 / $2,476.30
| Professional | | $1,112.10 | $1,539.25 | $2,476.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.78 / $1,846.22 / $2,634.03
| Professional | | $1,538.78 | $1,846.22 | $2,634.03 |
- 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
- $1,049.59 / $1,777.89 / $2,975.13
| Professional | | $1,049.59 | $1,777.89 | $2,975.13 |