- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.26 / $3,706.14 / $4,026.21
| Facility | | $3,438.26 | $3,706.14 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,960.20 / $2,553.53 / $2,749.10
| Professional | | $1,960.20 | $2,553.53 | $2,749.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $5,129.76 / $5,129.76
| Professional | | $0.02 | $5,129.76 | $5,129.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,525.92 / $3,042.79 / $5,520.64
| Professional | | $2,525.92 | $3,042.79 | $5,520.64 |
- 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
- $2,086.88 / $3,518.54 / $5,110.28
| Professional | | $2,086.88 | $3,518.54 | $5,110.28 |