- 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
- $792.97 / $1,256.94 / $1,563.83
| Professional | | $792.97 | $1,256.94 | $1,563.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.08 / $1,461.71 / $2,000.14
| Professional | | $1,056.08 | $1,461.71 | $2,000.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.61 / $1,533.37 / $2,455.73
| Professional | | $1,404.61 | $1,533.37 | $2,455.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.80 / $1,531.64 / $2,515.67
| Professional | | $988.80 | $1,531.64 | $2,515.67 |