- 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
- $907.39 / $1,675.61 / $1,771.98
| Professional | | $907.39 | $1,675.61 | $1,771.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.47 / $1,772.32 / $2,709.73
| Professional | | $1,506.47 | $1,772.32 | $2,709.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.63 / $1,809.84 / $3,127.12
| Professional | | $1,380.63 | $1,809.84 | $3,127.12 |
- 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
- $1,426.98 / $1,637.72 / $3,052.22
| Professional | | $1,426.98 | $1,637.72 | $3,052.22 |