- 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
- $770.34 / $1,228.02 / $1,433.94
| Professional | | $770.34 | $1,228.02 | $1,433.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.08 / $1,271.85 / $1,969.08
| Professional | | $1,081.08 | $1,271.85 | $1,969.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.91 / $1,474.54 / $2,336.38
| Professional | | $1,014.91 | $1,474.54 | $2,336.38 |
- 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
- $1,109.50 / $1,414.47 / $2,157.12
| Professional | | $1,109.50 | $1,414.47 | $2,157.12 |