- 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
- $786.81 / $1,433.97 / $1,484.47
| Professional | | $786.81 | $1,433.97 | $1,484.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.93 / $1,521.09 / $2,267.48
| Professional | | $1,292.93 | $1,521.09 | $2,267.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.91 / $1,613.38 / $2,681.38
| Professional | | $1,180.91 | $1,613.38 | $2,681.38 |
- 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
- $1,219.47 / $1,668.61 / $3,483.07
| Professional | | $1,219.47 | $1,668.61 | $3,483.07 |