- 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
- $720.94 / $1,272.50 / $1,414.54
| Professional | | $720.94 | $1,272.50 | $1,414.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.28 / $1,308.56 / $2,140.08
| Professional | | $1,112.28 | $1,308.56 | $2,140.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.23 / $1,511.88 / $2,314.06
| Professional | | $1,051.23 | $1,511.88 | $2,314.06 |
- 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
- $1,220.33 / $1,460.04 / $2,256.82
| Professional | | $1,220.33 | $1,460.04 | $2,256.82 |