- 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
- $1,539.53 / $2,827.82 / $2,934.99
| Professional | | $1,539.53 | $2,827.82 | $2,934.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,589.44 / $3,046.40 / $4,644.33
| Professional | | $2,589.44 | $3,046.40 | $4,644.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,399.28 / $3,397.98 / $5,394.47
| Professional | | $2,399.28 | $3,397.98 | $5,394.47 |
- 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
- $2,476.83 / $3,397.38 / $5,186.39
| Professional | | $2,476.83 | $3,397.38 | $5,186.39 |