- 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
- $2,646.94 / $3,660.58 / $5,153.38
| Professional | | $2,646.94 | $3,660.58 | $5,153.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,683.22 / $3,713.80 / $6,415.43
| Professional | | $2,683.22 | $3,713.80 | $6,415.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.79 / $4,798.93 / $6,255.57
| Professional | | $3,715.79 | $4,798.93 | $6,255.57 |
- 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
- $2,625.45 / $4,229.39 / $6,876.49
| Professional | | $2,625.45 | $4,229.39 | $6,876.49 |