- 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
- $913.45 / $1,665.28 / $1,753.87
| Professional | | $913.45 | $1,665.28 | $1,753.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,578.42 / $1,856.97 / $2,604.13
| Professional | | $1,578.42 | $1,856.97 | $2,604.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.00 / $2,220.30 / $4,025.40
| Professional | | $1,195.00 | $2,220.30 | $4,025.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $3,447.00 / $7,350.00
| Facility | | $2,569.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.86 / $2,011.96 / $3,197.79
| Professional | | $1,377.86 | $2,011.96 | $3,197.79 |