- 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
- $727.93 / $1,368.83 / $1,389.77
| Professional | | $727.93 | $1,368.83 | $1,389.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.49 / $1,499.40 / $2,124.66
| Professional | | $1,274.49 | $1,499.40 | $2,124.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.51 / $1,777.71 / $3,193.22
| Professional | | $922.51 | $1,777.71 | $3,193.22 |
- 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
- $1,027.43 / $1,581.68 / $2,494.86
| Professional | | $1,027.43 | $1,581.68 | $2,494.86 |