- 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
- $918.03 / $1,741.29 / $1,806.88
| Professional | | $918.03 | $1,741.29 | $1,806.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,559.43 / $1,834.62 / $2,748.02
| Professional | | $1,559.43 | $1,834.62 | $2,748.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.04 / $2,022.10 / $3,232.78
| Professional | | $1,424.04 | $2,022.10 | $3,232.78 |
- 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
- $1,558.09 / $1,839.83 / $3,081.80
| Professional | | $1,558.09 | $1,839.83 | $3,081.80 |