- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $4,937.68
| Facility | | $3,706.14 | $3,955.04 | $4,937.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,644.67 / $2,361.30 / $2,817.66
| Professional | | $1,644.67 | $2,361.30 | $2,817.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.20 / $2,151.14 / $3,502.76
| Professional | | $1,554.20 | $2,151.14 | $3,502.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,240.77 / $2,960.87 / $3,793.27
| Professional | | $2,240.77 | $2,960.87 | $3,793.27 |
- 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
- $1,637.15 / $2,558.73 / $3,973.48
| Professional | | $1,637.15 | $2,558.73 | $3,973.48 |