- 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
- $1,479.18 / $2,763.26 / $2,954.92
| Professional | | $1,479.18 | $2,763.26 | $2,954.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,350.87 / $2,765.73 / $4,463.35
| Professional | | $2,350.87 | $2,765.73 | $4,463.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,275.73 / $3,187.66 / $5,030.26
| Professional | | $2,275.73 | $3,187.66 | $5,030.26 |
- 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
- $2,390.50 / $2,768.35 / $4,906.27
| Professional | | $2,390.50 | $2,768.35 | $4,906.27 |