- 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
- $805.40 / $1,531.51 / $1,666.53
| Professional | | $805.40 | $1,531.51 | $1,666.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.83 / $1,572.74 / $2,454.76
| Professional | | $1,336.83 | $1,572.74 | $2,454.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.16 / $1,815.89 / $2,782.14
| Professional | | $1,265.16 | $1,815.89 | $2,782.14 |
- 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
- $1,432.55 / $1,763.58 / $2,713.25
| Professional | | $1,432.55 | $1,763.58 | $2,713.25 |