- 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
- $516.71 / $959.06 / $1,006.82
| Professional | | $516.71 | $959.06 | $1,006.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.59 / $1,028.93 / $1,533.48
| Professional | | $874.59 | $1,028.93 | $1,533.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $789.16 / $1,147.25 / $1,809.29
| Professional | | $789.16 | $1,147.25 | $1,809.29 |
- 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
- $813.82 / $1,027.29 / $1,768.40
| Professional | | $813.82 | $1,027.29 | $1,768.40 |