- 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
- $581.25 / $1,016.52 / $1,086.14
| Professional | | $581.25 | $1,016.52 | $1,086.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.30 / $1,055.65 / $1,685.36
| Professional | | $897.30 | $1,055.65 | $1,685.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.20 / $1,222.85 / $1,873.99
| Professional | | $840.20 | $1,222.85 | $1,873.99 |
- 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
- $929.65 / $1,185.77 / $1,826.14
| Professional | | $929.65 | $1,185.77 | $1,826.14 |