- 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
- $871.13 / $1,653.34 / $1,866.35
| Professional | | $871.13 | $1,653.34 | $1,866.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.15 / $1,703.71 / $2,672.75
| Professional | | $1,448.15 | $1,703.71 | $2,672.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,363.87 / $1,620.90 / $3,008.32
| Professional | | $1,363.87 | $1,620.90 | $3,008.32 |
- 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
- $1,330.30 / $1,903.79 / $2,934.32
| Professional | | $1,330.30 | $1,903.79 | $2,934.32 |