- 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
- $834.20 / $1,545.52 / $1,555.59
| Professional | | $834.20 | $1,545.52 | $1,555.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.67 / $1,634.90 / $2,455.61
| Professional | | $1,389.67 | $1,634.90 | $2,455.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.08 / $1,674.30 / $2,886.56
| Professional | | $1,274.08 | $1,674.30 | $2,886.56 |
- 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
- $1,340.29 / $1,641.30 / $2,817.70
| Professional | | $1,340.29 | $1,641.30 | $2,817.70 |