- 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
- $1,025.42 / $1,438.27 / $1,655.77
| Professional | | $1,025.42 | $1,438.27 | $1,655.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.09 / $1,346.84 / $2,161.88
| Professional | | $973.09 | $1,346.84 | $2,161.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,402.97 / $1,774.65 / $2,323.71
| Professional | | $1,402.97 | $1,774.65 | $2,323.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,007.00 / $6,315.00 / $12,945.00
| Facility | | $3,007.00 | $6,315.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.27 / $1,610.72 / $2,480.15
| Professional | | $1,002.27 | $1,610.72 | $2,480.15 |