- 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
- $965.03 / $1,443.24 / $1,738.67
| Professional | | $965.03 | $1,443.24 | $1,738.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.33 / $1,658.04 / $2,612.98
| Professional | | $1,409.33 | $1,658.04 | $2,612.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.00 / $2,240.98 / $3,274.74
| Professional | | $600.00 | $2,240.98 | $3,274.74 |
- 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
- $1,265.50 / $2,013.35 / $3,052.36
| Professional | | $1,265.50 | $2,013.35 | $3,052.36 |