- 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
- $2,468.00 / $2,566.80 / $2,808.12
| Professional | | $2,468.00 | $2,566.80 | $2,808.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,655.54 / $3,124.16 / $4,174.52
| Professional | | $2,655.54 | $3,124.16 | $4,174.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.00 / $3,506.53 / $5,241.84
| Professional | | $750.00 | $3,506.53 | $5,241.84 |
- 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
- $2,112.98 / $3,633.46 / $5,592.96
| Professional | | $2,112.98 | $3,633.46 | $5,592.96 |