- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,447.48 / $3,917.20 / $4,136.97
| Facility | | $3,447.48 | $3,917.20 | $4,136.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,440.13 / $5,440.13 / $6,800.16
| Professional | | $5,440.13 | $5,440.13 | $6,800.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,017.00 / $3,017.00 / $3,231.43
| Facility | | $3,017.00 | $3,017.00 | $3,231.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,418.00 / $2,418.00 / $2,418.00
| Professional | | $2,418.00 | $2,418.00 | $2,418.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,933.60 / $7,933.60 / $7,933.60
| Professional | | $7,933.60 | $7,933.60 | $7,933.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,870.26 / $7,134.16 / $7,134.16
| Facility | | $3,870.26 | $7,134.16 | $7,134.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,500.82 / $12,500.82 / $12,500.82
| Professional | | $12,500.82 | $12,500.82 | $12,500.82 |