- 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
- $2,581.30 / $3,153.37 / $4,556.27
| Professional | | $2,581.30 | $3,153.37 | $4,556.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,386.60 / $9,808.65 / $11,134.41
| Facility | | $9,386.60 | $9,808.65 | $11,134.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,589.15 / $2,963.71 / $6,091.04
| Professional | | $2,589.15 | $2,963.71 | $6,091.04 |
- 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
- $2,380.80 / $3,399.32 / $5,963.42
| Professional | | $2,380.80 | $3,399.32 | $5,963.42 |