- 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
- $906.87 / $1,708.61 / $1,793.89
| Professional | | $906.87 | $1,708.61 | $1,793.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,520.91 / $1,789.30 / $2,710.45
| Professional | | $1,520.91 | $1,789.30 | $2,710.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,399.36 / $1,876.88 / $3,171.49
| Professional | | $1,399.36 | $1,876.88 | $3,171.49 |
- 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
- $1,431.81 / $1,972.29 / $3,097.12
| Professional | | $1,431.81 | $1,972.29 | $3,097.12 |