- 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
- $1,375.81 / $2,623.02 / $2,710.34
| Professional | | $1,375.81 | $2,623.02 | $2,710.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,315.81 / $2,724.48 / $4,350.84
| Professional | | $2,315.81 | $2,724.48 | $4,350.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,143.31 / $2,991.19 / $4,824.06
| Professional | | $2,143.31 | $2,991.19 | $4,824.06 |
- 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
- $2,214.46 / $3,025.65 / $4,709.71
| Professional | | $2,214.46 | $3,025.65 | $4,709.71 |