- 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
- $987.89 / $1,292.16 / $1,626.73
| Professional | | $987.89 | $1,292.16 | $1,626.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.92 / $1,299.54 / $2,078.16
| Professional | | $938.92 | $1,299.54 | $2,078.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.68 / $1,604.33 / $2,299.78
| Professional | | $1,353.68 | $1,604.33 | $2,299.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $7,228.00 / $12,680.00
| Facility | | $3,219.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.06 / $1,574.51 / $2,357.44
| Professional | | $984.06 | $1,574.51 | $2,357.44 |