- 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
- $960.46 / $1,804.43 / $1,893.45
| Professional | | $960.46 | $1,804.43 | $1,893.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,614.37 / $1,899.26 / $2,824.07
| Professional | | $1,614.37 | $1,899.26 | $2,824.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,474.26 / $2,118.86 / $3,348.62
| Professional | | $1,474.26 | $2,118.86 | $3,348.62 |
- 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
- $1,638.38 / $1,998.34 / $3,191.39
| Professional | | $1,638.38 | $1,998.34 | $3,191.39 |