- 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
- $757.25 / $1,370.14 / $1,405.96
| Professional | | $757.25 | $1,370.14 | $1,405.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.23 / $1,322.12 / $1,747.40
| Professional | | $955.23 | $1,322.12 | $1,747.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,374.45 / $1,548.85 / $2,258.58
| Professional | | $1,374.45 | $1,548.85 | $2,258.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.18 / $1,447.27 / $2,058.67
| Professional | | $790.18 | $1,447.27 | $2,058.67 |