- 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
- $660.65 / $1,241.89 / $1,276.10
| Professional | | $660.65 | $1,241.89 | $1,276.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,118.86 / $1,316.32 / $1,944.81
| Professional | | $1,118.86 | $1,316.32 | $1,944.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.92 / $1,281.29 / $2,314.37
| Professional | | $1,014.92 | $1,281.29 | $2,314.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $4,915.00 / $7,205.00
| Facility | | $1,649.00 | $4,915.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $951.57 / $1,433.31 / $2,262.58
| Professional | | $951.57 | $1,433.31 | $2,262.58 |