- 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
- $746.56 / $1,425.86 / $1,468.22
| Professional | | $746.56 | $1,425.86 | $1,468.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,269.93 / $1,494.03 / $2,363.42
| Professional | | $1,269.93 | $1,494.03 | $2,363.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.22 / $1,706.55 / $2,639.88
| Professional | | $1,167.22 | $1,706.55 | $2,639.88 |
- 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
- $1,263.60 / $1,651.82 / $2,579.23
| Professional | | $1,263.60 | $1,651.82 | $2,579.23 |