- 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
- $868.60 / $1,249.26 / $1,705.73
| Professional | | $868.60 | $1,249.26 | $1,705.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.13 / $1,227.85 / $2,186.63
| Professional | | $887.13 | $1,227.85 | $2,186.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.85 / $1,654.02 / $2,053.42
| Professional | | $1,227.85 | $1,654.02 | $2,053.42 |
- 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
- $910.99 / $1,423.36 / $2,203.76
| Professional | | $910.99 | $1,423.36 | $2,203.76 |