- 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
- $735.24 / $1,169.85 / $1,252.81
| Professional | | $735.24 | $1,169.85 | $1,252.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.46 / $1,211.13 / $2,136.40
| Professional | | $1,029.46 | $1,211.13 | $2,136.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.42 / $1,404.97 / $2,138.90
| Professional | | $967.42 | $1,404.97 | $2,138.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $4,086.00 / $9,622.00
| Facility | | $3,146.00 | $4,086.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.83 / $1,342.05 / $2,087.38
| Professional | | $1,083.83 | $1,342.05 | $2,087.38 |