- 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
- $914.47 / $1,741.02 / $1,890.77
| Professional | | $914.47 | $1,741.02 | $1,890.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,521.02 / $1,789.43 / $2,787.37
| Professional | | $1,521.02 | $1,789.43 | $2,787.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.64 / $2,066.71 / $3,164.31
| Professional | | $1,436.64 | $2,066.71 | $3,164.31 |
- 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
- $1,464.88 / $1,997.19 / $3,086.07
| Professional | | $1,464.88 | $1,997.19 | $3,086.07 |