- 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
- $2,156.81 / $2,263.94 / $3,046.33
| Professional | | $2,156.81 | $2,263.94 | $3,046.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,555.46 / $3,006.42 / $4,843.17
| Professional | | $2,555.46 | $3,006.42 | $4,843.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $3,713.24 / $5,182.25
| Professional | | $250.00 | $3,713.24 | $5,182.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $3,630.00 / $7,205.00
| Facility | | $1,649.00 | $3,630.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,267.25 / $2,667.35 / $5,149.76
| Professional | | $2,267.25 | $2,667.35 | $5,149.76 |