- 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
- $744.12 / $1,415.96 / $1,520.78
| Professional | | $744.12 | $1,415.96 | $1,520.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,240.58 / $1,459.50 / $2,232.35
| Professional | | $1,240.58 | $1,459.50 | $2,232.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,169.15 / $1,688.21 / $2,579.69
| Professional | | $1,169.15 | $1,688.21 | $2,579.69 |
- 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
- $1,310.09 / $1,624.27 / $2,516.39
| Professional | | $1,310.09 | $1,624.27 | $2,516.39 |