- 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
- $860.27 / $1,637.37 / $1,875.90
| Professional | | $860.27 | $1,637.37 | $1,875.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.17 / $1,683.73 / $2,619.05
| Professional | | $1,431.17 | $1,683.73 | $2,619.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.46 / $1,945.41 / $2,976.76
| Professional | | $1,352.46 | $1,945.41 | $2,976.76 |
- 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
- $1,376.46 / $1,637.47 / $2,872.24
| Professional | | $1,376.46 | $1,637.47 | $2,872.24 |