- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $5,496.04
| Facility | | $3,706.14 | $3,955.04 | $5,496.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $653.04 / $1,657.38 / $4,887.85
| Professional | | $653.04 | $1,657.38 | $4,887.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $686.83 / $2,141.19 / $4,146.05
| Professional | | $686.83 | $2,141.19 | $4,146.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $986.47 / $1,523.34 / $5,778.84
| Professional | | $986.47 | $1,523.34 | $5,778.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,080.00 / $3,912.00 / $7,350.00
| Facility | | $2,080.00 | $3,912.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,053.44 / $4,068.50 / $6,327.40
| Professional | | $2,053.44 | $4,068.50 | $6,327.40 |