- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $4,937.68
| Facility | | $3,706.14 | $3,955.04 | $4,937.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.55 / $1,510.87 / $1,809.72
| Professional | | $1,087.55 | $1,510.87 | $1,809.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $1,555.32 / $1,555.32
| Professional | | $0.02 | $1,555.32 | $1,555.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.81 / $1,859.30 / $2,491.82
| Professional | | $1,427.81 | $1,859.30 | $2,491.82 |
- 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
- $926.29 / $1,536.53 / $2,347.91
| Professional | | $926.29 | $1,536.53 | $2,347.91 |