- 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
- $964.15 / $1,788.53 / $1,862.29
| Professional | | $964.15 | $1,788.53 | $1,862.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,606.28 / $1,889.74 / $2,843.04
| Professional | | $1,606.28 | $1,889.74 | $2,843.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,474.70 / $2,039.70 / $3,336.79
| Professional | | $1,474.70 | $2,039.70 | $3,336.79 |
- 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
- $1,463.53 / $1,916.46 / $3,191.66
| Professional | | $1,463.53 | $1,916.46 | $3,191.66 |