- 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
- $758.20 / $1,341.23 / $1,421.13
| Professional | | $758.20 | $1,341.23 | $1,421.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.46 / $1,420.54 / $2,131.51
| Professional | | $1,207.46 | $1,420.54 | $2,131.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,095.75 / $1,534.98 / $2,498.34
| Professional | | $1,095.75 | $1,534.98 | $2,498.34 |
- 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
- $1,224.32 / $1,548.35 / $2,442.38
| Professional | | $1,224.32 | $1,548.35 | $2,442.38 |