- 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
- $985.54 / $1,461.40 / $2,154.44
| Professional | | $985.54 | $1,461.40 | $2,154.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,637.98 / $1,927.03 / $3,005.17
| Professional | | $1,637.98 | $1,927.03 | $3,005.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.10 / $2,224.71 / $3,409.89
| Professional | | $1,550.10 | $2,224.71 | $3,409.89 |
- 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
- $1,624.40 / $2,153.46 / $3,325.40
| Professional | | $1,624.40 | $2,153.46 | $3,325.40 |