- 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
- $935.86 / $1,746.48 / $1,830.22
| Professional | | $935.86 | $1,746.48 | $1,830.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,568.92 / $1,845.79 / $2,808.90
| Professional | | $1,568.92 | $1,845.79 | $2,808.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,439.81 / $1,812.10 / $3,257.81
| Professional | | $1,439.81 | $1,812.10 | $3,257.81 |
- 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
- $1,371.28 / $2,034.11 / $3,179.57
| Professional | | $1,371.28 | $2,034.11 | $3,179.57 |