- 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
- $835.96 / $1,580.14 / $1,637.65
| Professional | | $835.96 | $1,580.14 | $1,637.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,419.09 / $1,669.52 / $2,497.16
| Professional | | $1,419.09 | $1,669.52 | $2,497.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.03 / $1,846.83 / $2,938.22
| Professional | | $1,291.03 | $1,846.83 | $2,938.22 |
- 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
- $1,374.10 / $1,822.62 / $2,872.08
| Professional | | $1,374.10 | $1,822.62 | $2,872.08 |