- 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
- $1,875.42 / $2,612.50 / $3,504.42
| Professional | | $1,875.42 | $2,612.50 | $3,504.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,888.51 / $2,613.86 / $4,663.54
| Professional | | $1,888.51 | $2,613.86 | $4,663.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,613.86 / $3,426.43 / $4,537.82
| Professional | | $2,613.86 | $3,426.43 | $4,537.82 |
- 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
- $1,869.11 / $3,069.20 / $4,843.60
| Professional | | $1,869.11 | $3,069.20 | $4,843.60 |