- 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
- $733.74 / $1,394.81 / $1,632.87
| Professional | | $733.74 | $1,394.81 | $1,632.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,218.68 / $1,433.74 / $2,531.86
| Professional | | $1,218.68 | $1,433.74 | $2,531.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.15 / $1,655.63 / $2,590.16
| Professional | | $1,152.15 | $1,655.63 | $2,590.16 |
- 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
- $1,174.72 / $1,601.58 / $2,471.96
| Professional | | $1,174.72 | $1,601.58 | $2,471.96 |