- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $1,543.03 / $3,955.04
| Facility | | $1,518.41 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.60 / $1,738.39 / $2,235.73
| Professional | | $1,718.60 | $1,738.39 | $2,235.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,822.88 / $2,144.56 / $3,324.59
| Professional | | $1,822.88 | $2,144.56 | $3,324.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $2,337.64 / $3,588.44
| Professional | | $350.00 | $2,337.64 | $3,588.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $3,447.00 / $7,350.00
| Facility | | $2,654.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.28 / $2,444.30 / $3,545.76
| Professional | | $1,554.28 | $2,444.30 | $3,545.76 |