- 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
- $1,404.46 / $2,680.80 / $2,751.94
| Professional | | $1,404.46 | $2,680.80 | $2,751.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,378.27 / $2,797.96 / $4,192.47
| Professional | | $2,378.27 | $2,797.96 | $4,192.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,190.27 / $3,063.73 / $4,946.05
| Professional | | $2,190.27 | $3,063.73 | $4,946.05 |
- 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
- $2,371.67 / $3,090.76 / $4,739.26
| Professional | | $2,371.67 | $3,090.76 | $4,739.26 |