- 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
- $2,588.54 / $3,573.38 / $5,095.72
| Professional | | $2,588.54 | $3,573.38 | $5,095.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,623.60 / $3,631.28 / $6,274.83
| Professional | | $2,623.60 | $3,631.28 | $6,274.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,634.72 / $4,683.12 / $6,119.75
| Professional | | $3,634.72 | $4,683.12 | $6,119.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $2,257.00 / $6,383.00
| Facility | | $1,649.00 | $2,257.00 | $6,383.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,525.32 / $3,605.96 / $5,707.59
| Professional | | $2,525.32 | $3,605.96 | $5,707.59 |