- 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
- $1,585.03 / $2,946.71 / $3,102.77
| Professional | | $1,585.03 | $2,946.71 | $3,102.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,621.31 / $3,083.89 / $4,768.96
| Professional | | $2,621.31 | $3,083.89 | $4,768.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,010.45 / $2,671.28 / $5,460.00
| Professional | | $2,010.45 | $2,671.28 | $5,460.00 |
- 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
- $1,653.34 / $3,436.16 / $5,324.48
| Professional | | $1,653.34 | $3,436.16 | $5,324.48 |