- 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
- $962.47 / $1,817.52 / $1,923.16
| Professional | | $962.47 | $1,817.52 | $1,923.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.09 / $1,715.40 / $2,871.14
| Professional | | $1,458.09 | $1,715.40 | $2,871.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,495.03 / $1,981.22 / $3,393.73
| Professional | | $1,495.03 | $1,981.22 | $3,393.73 |
- 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
- $1,422.57 / $2,082.57 / $3,311.24
| Professional | | $1,422.57 | $2,082.57 | $3,311.24 |