- 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
- $2,908.55 / $2,918.66 / $3,875.18
| Professional | | $2,908.55 | $2,918.66 | $3,875.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,077.52 / $3,620.61 / $5,658.06
| Professional | | $3,077.52 | $3,620.61 | $5,658.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.00 / $3,504.89 / $5,987.24
| Professional | | $400.00 | $3,504.89 | $5,987.24 |
- 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
- $2,586.94 / $4,150.14 / $6,002.21
| Professional | | $2,586.94 | $4,150.14 | $6,002.21 |