- 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
- $868.24 / $1,641.57 / $1,710.50
| Professional | | $868.24 | $1,641.57 | $1,710.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,476.56 / $1,737.13 / $2,564.78
| Professional | | $1,476.56 | $1,737.13 | $2,564.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,339.79 / $1,753.34 / $3,055.18
| Professional | | $1,339.79 | $1,753.34 | $3,055.18 |
- 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
- $1,442.73 / $1,780.90 / $2,906.56
| Professional | | $1,442.73 | $1,780.90 | $2,906.56 |