- 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
- $814.56 / $1,078.69 / $1,446.32
| Professional | | $814.56 | $1,078.69 | $1,446.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.20 / $1,132.46 / $1,935.23
| Professional | | $818.20 | $1,132.46 | $1,935.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,134.09 / $1,413.43 / $1,912.46
| Professional | | $1,134.09 | $1,413.43 | $1,912.46 |
- 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
- $785.32 / $1,286.46 / $2,044.27
| Professional | | $785.32 | $1,286.46 | $2,044.27 |