- 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
- $1,143.97 / $3,006.37 / $3,164.60
| Professional | | $1,143.97 | $3,006.37 | $3,164.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,325.74 / $5,830.86 / $6,903.05
| Facility | | $3,325.74 | $5,830.86 | $6,903.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $3,447.00 / $7,350.00
| Facility | | $2,654.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.42 / $2,602.17 / $3,788.49
| Professional | | $2,041.42 | $2,602.17 | $3,788.49 |