- 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
- $804.03 / $1,534.24 / $1,621.10
| Professional | | $804.03 | $1,534.24 | $1,621.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.16 / $1,617.83 / $2,534.11
| Professional | | $1,375.16 | $1,617.83 | $2,534.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.54 / $1,743.66 / $2,850.25
| Professional | | $1,253.54 | $1,743.66 | $2,850.25 |
- 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
- $1,394.42 / $1,776.17 / $2,785.85
| Professional | | $1,394.42 | $1,776.17 | $2,785.85 |