- 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
- $2,032.85 / $2,209.62 / $2,416.46
| Professional | | $2,032.85 | $2,209.62 | $2,416.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.38 / $2,471.03 / $4,250.39
| Professional | | $2,100.38 | $2,471.03 | $4,250.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.00 / $2,802.64 / $4,164.77
| Professional | | $550.00 | $2,802.64 | $4,164.77 |
- 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
- $1,891.78 / $2,861.35 / $4,406.43
| Professional | | $1,891.78 | $2,861.35 | $4,406.43 |