- 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
- $539.87 / $1,017.87 / $1,081.38
| Professional | | $539.87 | $1,017.87 | $1,081.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.12 / $1,055.43 / $1,630.62
| Professional | | $897.12 | $1,055.43 | $1,630.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.24 / $1,068.06 / $1,875.27
| Professional | | $841.24 | $1,068.06 | $1,875.27 |
- 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
- $890.24 / $1,194.91 / $1,827.27
| Professional | | $890.24 | $1,194.91 | $1,827.27 |