- 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
- $854.56 / $1,629.73 / $1,648.90
| Professional | | $854.56 | $1,629.73 | $1,648.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,462.17 / $1,720.20 / $2,647.50
| Professional | | $1,462.17 | $1,720.20 | $2,647.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.64 / $1,765.87 / $3,029.23
| Professional | | $1,331.64 | $1,765.87 | $3,029.23 |
- 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
- $1,424.43 / $1,880.31 / $2,960.90
| Professional | | $1,424.43 | $1,880.31 | $2,960.90 |