- 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
- $768.87 / $1,239.08 / $1,446.10
| Professional | | $768.87 | $1,239.08 | $1,446.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.58 / $1,279.52 / $2,269.35
| Professional | | $1,087.58 | $1,279.52 | $2,269.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,024.63 / $1,481.58 / $2,394.32
| Professional | | $1,024.63 | $1,481.58 | $2,394.32 |
- 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
- $1,111.70 / $1,421.78 / $2,205.34
| Professional | | $1,111.70 | $1,421.78 | $2,205.34 |