- 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
- $839.84 / $1,300.53 / $1,523.42
| Professional | | $839.84 | $1,300.53 | $1,523.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.09 / $1,466.00 / $2,281.94
| Professional | | $1,246.09 | $1,466.00 | $2,281.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $1,970.96 / $2,907.81
| Professional | | $500.00 | $1,970.96 | $2,907.81 |
- 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
- $1,290.56 / $1,850.26 / $2,594.87
| Professional | | $1,290.56 | $1,850.26 | $2,594.87 |