- 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
- $1,218.08 / $2,659.27 / $2,925.47
| Professional | | $1,218.08 | $2,659.27 | $2,925.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,280.68 / $12,982.03 / $15,796.22
| Facility | | $4,280.68 | $12,982.03 | $15,796.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.87 / $2,008.13 / $2,008.13
| Professional | | $1,450.87 | $2,008.13 | $2,008.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.02 / $1,527.67 / $2,741.13
| Professional | | $525.02 | $1,527.67 | $2,741.13 |