- 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
- $1,523.77 / $2,911.13 / $3,321.24
| Professional | | $1,523.77 | $2,911.13 | $3,321.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,533.61 / $2,980.72 / $4,656.81
| Professional | | $2,533.61 | $2,980.72 | $4,656.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,403.83 / $3,278.37 / $5,276.62
| Professional | | $2,403.83 | $3,278.37 | $5,276.62 |
- 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
- $2,451.92 / $3,341.42 / $5,144.47
| Professional | | $2,451.92 | $3,341.42 | $5,144.47 |