- 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
- $527.01 / $1,000.75 / $1,041.46
| Professional | | $527.01 | $1,000.75 | $1,041.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.89 / $1,055.16 / $1,566.22
| Professional | | $896.89 | $1,055.16 | $1,566.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.47 / $1,064.46 / $1,857.76
| Professional | | $817.47 | $1,064.46 | $1,857.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $4,915.00 / $7,205.00
| Facility | | $1,649.00 | $4,915.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.61 / $1,151.63 / $1,815.72
| Professional | | $841.61 | $1,151.63 | $1,815.72 |