- 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
- $1,576.13 / $2,596.82 / $2,963.08
| Professional | | $1,576.13 | $2,596.82 | $2,963.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,261.46 / $2,660.55 / $4,159.67
| Professional | | $2,261.46 | $2,660.55 | $4,159.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,145.04 / $2,935.92 / $5,056.32
| Professional | | $2,145.04 | $2,935.92 | $5,056.32 |
- 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
- $2,187.75 / $2,981.61 / $4,590.66
| Professional | | $2,187.75 | $2,981.61 | $4,590.66 |