- 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
- $652.41 / $1,138.61 / $1,274.57
| Professional | | $652.41 | $1,138.61 | $1,274.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.47 / $1,173.49 / $1,897.42
| Professional | | $997.47 | $1,173.49 | $1,897.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.47 / $1,128.70 / $2,074.11
| Professional | | $940.47 | $1,128.70 | $2,074.11 |
- 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
- $925.24 / $1,307.30 / $2,001.03
| Professional | | $925.24 | $1,307.30 | $2,001.03 |