- 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
- $354.41 / $1,981.86 / $2,111.71
| Professional | | $354.41 | $1,981.86 | $2,111.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,325.74 / $5,830.86 / $6,903.05
| Facility | | $3,325.74 | $5,830.86 | $6,903.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $3,447.00 / $7,350.00
| Facility | | $2,654.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,175.18 / $2,602.17 / $3,288.32
| Professional | | $1,175.18 | $2,602.17 | $3,288.32 |