- 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
- $685.38 / $1,193.59 / $1,300.84
| Professional | | $685.38 | $1,193.59 | $1,300.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,140.28 / $1,341.51 / $2,084.53
| Professional | | $1,140.28 | $1,341.51 | $2,084.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.79 / $1,352.53 / $2,370.17
| Professional | | $1,073.79 | $1,352.53 | $2,370.17 |
- 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
- $1,028.49 / $1,491.54 / $2,312.23
| Professional | | $1,028.49 | $1,491.54 | $2,312.23 |