- 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
- $824.25 / $1,689.29 / $1,742.32
| Professional | | $824.25 | $1,689.29 | $1,742.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,510.51 / $1,777.07 / $2,482.94
| Professional | | $1,510.51 | $1,777.07 | $2,482.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.48 / $1,694.08 / $3,142.65
| Professional | | $1,393.48 | $1,694.08 | $3,142.65 |
- 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
- $1,277.50 / $1,967.64 / $3,017.45
| Professional | | $1,277.50 | $1,967.64 | $3,017.45 |