- 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
- $2,194.19 / $2,396.53 / $2,600.86
| Professional | | $2,194.19 | $2,396.53 | $2,600.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,274.23 / $2,675.58 / $4,592.34
| Professional | | $2,274.23 | $2,675.58 | $4,592.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.00 / $3,093.65 / $4,471.63
| Professional | | $550.00 | $3,093.65 | $4,471.63 |
- 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
- $1,975.51 / $2,945.81 / $4,631.55
| Professional | | $1,975.51 | $2,945.81 | $4,631.55 |