- 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
- $907.08 / $1,214.54 / $1,789.76
| Professional | | $907.08 | $1,214.54 | $1,789.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,531.16 / $1,801.36 / $2,712.16
| Professional | | $1,531.16 | $1,801.36 | $2,712.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.75 / $1,778.22 / $3,177.85
| Professional | | $1,403.75 | $1,778.22 | $3,177.85 |
- 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
- $1,459.39 / $1,985.20 / $3,102.42
| Professional | | $1,459.39 | $1,985.20 | $3,102.42 |