- 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
- $686.92 / $1,219.71 / $1,260.20
| Professional | | $686.92 | $1,219.71 | $1,260.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.31 / $1,282.72 / $1,784.82
| Professional | | $1,090.31 | $1,282.72 | $1,784.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.27 / $1,406.74 / $2,260.85
| Professional | | $997.27 | $1,406.74 | $2,260.85 |
- 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
- $1,085.36 / $1,293.27 / $2,209.05
| Professional | | $1,085.36 | $1,293.27 | $2,209.05 |