- 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
- $648.91 / $1,232.36 / $1,337.69
| Professional | | $648.91 | $1,232.36 | $1,337.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.78 / $1,271.51 / $1,972.39
| Professional | | $1,080.78 | $1,271.51 | $1,972.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.91 / $1,472.15 / $2,246.19
| Professional | | $1,015.91 | $1,472.15 | $2,246.19 |
- 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
- $1,036.13 / $1,413.38 / $2,191.59
| Professional | | $1,036.13 | $1,413.38 | $2,191.59 |