- 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
- $1,431.27 / $1,988.09 / $2,380.90
| Professional | | $1,431.27 | $1,988.09 | $2,380.90 |
- 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
- $1,878.86 / $2,446.59 / $3,278.03
| Professional | | $1,878.86 | $2,446.59 | $3,278.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,609.00 / $5,979.00 / $12,680.00
| Facility | | $2,609.00 | $5,979.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,146.83 / $1,718.82 / $2,964.54
| Professional | | $1,146.83 | $1,718.82 | $2,964.54 |