- 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
- $874.21 / $1,125.74 / $1,583.36
| Professional | | $874.21 | $1,125.74 | $1,583.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $890.26 / $1,232.19 / $2,003.82
| Professional | | $890.26 | $1,232.19 | $2,003.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.07 / $1,482.74 / $2,010.21
| Professional | | $1,216.07 | $1,482.74 | $2,010.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $2,257.00 / $6,383.00
| Facility | | $1,649.00 | $2,257.00 | $6,383.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.71 / $1,393.41 / $2,149.34
| Professional | | $810.71 | $1,393.41 | $2,149.34 |