- 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
- $672.00 / $1,277.22 / $1,384.39
| Professional | | $672.00 | $1,277.22 | $1,384.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,118.25 / $1,315.59 / $2,044.11
| Professional | | $1,118.25 | $1,315.59 | $2,044.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.66 / $1,521.60 / $2,325.54
| Professional | | $1,054.66 | $1,521.60 | $2,325.54 |
- 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
- $1,156.70 / $1,448.65 / $2,242.71
| Professional | | $1,156.70 | $1,448.65 | $2,242.71 |