- 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
- $788.04 / $1,270.76 / $1,450.90
| Professional | | $788.04 | $1,270.76 | $1,450.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,114.68 / $1,311.39 / $2,298.02
| Professional | | $1,114.68 | $1,311.39 | $2,298.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.69 / $1,517.38 / $2,538.44
| Professional | | $1,049.69 | $1,517.38 | $2,538.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,596.00 / $7,457.00 / $12,945.00
| Facility | | $4,596.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.87 / $1,458.97 / $2,259.08
| Professional | | $880.87 | $1,458.97 | $2,259.08 |