- 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
- $789.26 / $1,456.22 / $1,522.34
| Professional | | $789.26 | $1,456.22 | $1,522.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.64 / $1,543.10 / $2,333.67
| Professional | | $1,311.64 | $1,543.10 | $2,333.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.13 / $1,725.53 / $2,721.50
| Professional | | $1,201.13 | $1,725.53 | $2,721.50 |
- 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
- $1,315.35 / $1,695.50 / $2,656.74
| Professional | | $1,315.35 | $1,695.50 | $2,656.74 |