- 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
- $3,548.74 / $5,037.52 / $5,984.93
| Professional | | $3,548.74 | $5,037.52 | $5,984.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,357.27 / $4,646.74 / $7,621.56
| Professional | | $3,357.27 | $4,646.74 | $7,621.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,840.35 / $6,706.04 / $8,180.40
| Professional | | $4,840.35 | $6,706.04 | $8,180.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,505.00 / $7,819.00 / $19,195.00
| Facility | | $4,505.00 | $7,819.00 | $19,195.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,540.46 / $5,670.37 / $8,645.74
| Professional | | $3,540.46 | $5,670.37 | $8,645.74 |