- 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
- $1,707.54 / $3,203.79 / $3,394.30
| Professional | | $1,707.54 | $3,203.79 | $3,394.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,855.40 / $3,359.29 / $5,131.02
| Professional | | $2,855.40 | $3,359.29 | $5,131.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,641.12 / $2,926.62 / $5,944.12
| Professional | | $2,641.12 | $2,926.62 | $5,944.12 |
- 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
- $2,393.88 / $3,731.53 / $5,797.85
| Professional | | $2,393.88 | $3,731.53 | $5,797.85 |