- 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
- $615.41 / $975.83 / $1,203.59
| Professional | | $615.41 | $975.83 | $1,203.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.93 / $1,009.33 / $1,798.07
| Professional | | $857.93 | $1,009.33 | $1,798.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.76 / $1,141.02 / $2,022.91
| Professional | | $806.76 | $1,141.02 | $2,022.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.00 / $1,788.00 / $4,602.00
| Facility | | $1,069.00 | $1,788.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $853.64 / $1,256.00 / $1,927.56
| Professional | | $853.64 | $1,256.00 | $1,927.56 |