- 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
- $834.06 / $1,586.80 / $1,765.93
| Professional | | $834.06 | $1,586.80 | $1,765.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.80 / $1,630.35 / $2,544.17
| Professional | | $1,385.80 | $1,630.35 | $2,544.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.94 / $1,678.20 / $2,882.08
| Professional | | $1,310.94 | $1,678.20 | $2,882.08 |
- 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
- $1,379.86 / $1,820.86 / $2,810.54
| Professional | | $1,379.86 | $1,820.86 | $2,810.54 |