- 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
- $1,856.98 / $2,628.60 / $3,160.38
| Professional | | $1,856.98 | $2,628.60 | $3,160.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,758.40 / $2,433.78 / $3,826.18
| Professional | | $1,758.40 | $2,433.78 | $3,826.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,535.19 / $4,117.22 / $4,348.02
| Professional | | $2,535.19 | $4,117.22 | $4,348.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,007.00 / $6,315.00 / $12,945.00
| Facility | | $3,007.00 | $6,315.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,881.26 / $3,010.02 / $4,488.87
| Professional | | $1,881.26 | $3,010.02 | $4,488.87 |