- 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
- $664.08 / $1,208.08 / $1,262.32
| Professional | | $664.08 | $1,208.08 | $1,262.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.25 / $1,329.71 / $2,011.31
| Professional | | $1,130.25 | $1,329.71 | $2,011.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,032.91 / $1,520.21 / $2,342.62
| Professional | | $1,032.91 | $1,520.21 | $2,342.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,074.00 / $7,819.00 / $19,195.00
| Facility | | $5,074.00 | $7,819.00 | $19,195.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.57 / $1,457.19 / $2,289.33
| Professional | | $1,074.57 | $1,457.19 | $2,289.33 |