- 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
- $2,106.78 / $2,882.14 / $3,637.33
| Professional | | $2,106.78 | $2,882.14 | $3,637.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,136.71 / $2,957.40 / $5,089.13
| Professional | | $2,136.71 | $2,957.40 | $5,089.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,957.40 / $3,659.20 / $4,954.22
| Professional | | $2,957.40 | $3,659.20 | $4,954.22 |
- 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
- $2,038.61 / $3,349.98 / $5,286.64
| Professional | | $2,038.61 | $3,349.98 | $5,286.64 |