- 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
- $2,044.02 / $2,178.46 / $2,654.15
| Professional | | $2,044.02 | $2,178.46 | $2,654.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,151.08 / $2,530.67 / $3,914.69
| Professional | | $2,151.08 | $2,530.67 | $3,914.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $2,785.62 / $4,176.63
| Professional | | $500.00 | $2,785.62 | $4,176.63 |
- 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
- $1,576.13 / $2,895.09 / $3,798.90
| Professional | | $1,576.13 | $2,895.09 | $3,798.90 |