- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,403.82 / $3,403.82 / $3,505.98
| Facility | | $3,403.82 | $3,403.82 | $3,505.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,656.06 / $3,307.19 / $4,393.13
| Professional | | $2,656.06 | $3,307.19 | $4,393.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $926.48 / $926.48 / $926.48
| Facility | | $926.48 | $926.48 | $926.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,976.17 / $3,354.00 / $3,995.08
| Professional | | $2,976.17 | $3,354.00 | $3,995.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,657.49 / $3,657.49 / $3,657.49
| Facility | | $3,657.49 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $435.92 / $3,657.49 / $3,657.49
| Professional | | $435.92 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,526.24 / $2,022.10 / $3,519.93
| Professional | | $1,526.24 | $2,022.10 | $3,519.93 |