- 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
- $771.42 / $1,461.56 / $1,526.55
| Professional | | $771.42 | $1,461.56 | $1,526.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.98 / $1,542.33 / $2,286.52
| Professional | | $1,310.98 | $1,542.33 | $2,286.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,193.35 / $1,701.39 / $2,717.34
| Professional | | $1,193.35 | $1,701.39 | $2,717.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,685.00 / $8,200.00 / $27,485.00
| Facility | | $4,685.00 | $8,200.00 | $27,485.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,245.49 / $1,535.38 / $2,656.12
| Professional | | $1,245.49 | $1,535.38 | $2,656.12 |