- 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
- $1,368.83 / $2,545.78 / $2,682.09
| Professional | | $1,368.83 | $2,545.78 | $2,682.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,253.04 / $2,650.63 / $4,034.71
| Professional | | $2,253.04 | $2,650.63 | $4,034.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,080.65 / $2,878.79 / $4,688.66
| Professional | | $2,080.65 | $2,878.79 | $4,688.66 |
- 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
- $2,321.15 / $2,936.06 / $4,578.22
| Professional | | $2,321.15 | $2,936.06 | $4,578.22 |