- 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
- $941.37 / $1,052.83 / $1,559.66
| Professional | | $941.37 | $1,052.83 | $1,559.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.82 / $1,482.10 / $2,200.01
| Professional | | $1,070.82 | $1,482.10 | $2,200.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,268.34 / $1,541.57 / $2,436.59
| Professional | | $1,268.34 | $1,541.57 | $2,436.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,052.00 / $5,510.00
| Facility | | $1,812.00 | $4,052.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.05 / $1,535.41 / $2,558.73
| Professional | | $914.05 | $1,535.41 | $2,558.73 |