- 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
- $1,860.88 / $2,633.01 / $2,917.54
| Professional | | $1,860.88 | $2,633.01 | $2,917.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,762.19 / $2,439.02 / $4,110.64
| Professional | | $1,762.19 | $2,439.02 | $4,110.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,540.65 / $4,026.82 / $4,265.58
| Professional | | $2,540.65 | $4,026.82 | $4,265.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,836.81 / $2,956.76 / $4,014.26
| Professional | | $1,836.81 | $2,956.76 | $4,014.26 |