- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $5,496.04
| Facility | | $3,706.14 | $3,955.04 | $5,496.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.44 / $1,070.44 / $1,364.09
| Professional | | $730.44 | $1,070.44 | $1,364.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.78 / $1,007.30 / $1,697.09
| Professional | | $727.78 | $1,007.30 | $1,697.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.28 / $1,305.11 / $1,808.68
| Professional | | $1,049.28 | $1,305.11 | $1,808.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,080.00 / $3,912.00 / $7,350.00
| Facility | | $2,080.00 | $3,912.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $773.44 / $1,253.71 / $1,925.14
| Professional | | $773.44 | $1,253.71 | $1,925.14 |