- 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
- $2,007.38 / $3,766.57 / $3,953.21
| Professional | | $2,007.38 | $3,766.57 | $3,953.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,350.73 / $3,942.03 / $6,048.71
| Professional | | $3,350.73 | $3,942.03 | $6,048.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,011.20 / $3,415.46 / $6,979.84
| Professional | | $3,011.20 | $3,415.46 | $6,979.84 |
- 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
- $2,486.77 / $3,573.16 / $6,806.81
| Professional | | $2,486.77 | $3,573.16 | $6,806.81 |