- 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
- $876.09 / $1,563.54 / $1,771.75
| Professional | | $876.09 | $1,563.54 | $1,771.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.95 / $1,638.77 / $2,615.06
| Professional | | $1,392.95 | $1,638.77 | $2,615.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,279.21 / $1,735.04 / $2,895.76
| Professional | | $1,279.21 | $1,735.04 | $2,895.76 |
- 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
- $1,292.07 / $1,804.28 / $2,829.34
| Professional | | $1,292.07 | $1,804.28 | $2,829.34 |