- 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
- $2,678.69 / $3,240.48 / $4,151.42
| Professional | | $2,678.69 | $3,240.48 | $4,151.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,447.77 / $4,056.20 / $7,010.61
| Professional | | $3,447.77 | $4,056.20 | $7,010.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $4,915.00 / $7,205.00
| Facility | | $1,649.00 | $4,915.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,096.82 / $4,571.97 / $6,946.15
| Professional | | $3,096.82 | $4,571.97 | $6,946.15 |