- 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
- $1,268.78 / $2,228.54 / $2,397.69
| Professional | | $1,268.78 | $2,228.54 | $2,397.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,113.54 / $2,486.52 / $3,833.33
| Professional | | $2,113.54 | $2,486.52 | $3,833.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,980.65 / $2,878.96 / $4,415.26
| Professional | | $1,980.65 | $2,878.96 | $4,415.26 |
- 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
- $2,794.00 / $3,066.35 / $4,302.47
| Professional | | $2,794.00 | $3,066.35 | $4,302.47 |