- 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
- $620.59 / $1,178.72 / $1,366.90
| Professional | | $620.59 | $1,178.72 | $1,366.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.29 / $1,215.63 / $2,067.03
| Professional | | $1,033.29 | $1,215.63 | $2,067.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.40 / $1,406.84 / $2,219.63
| Professional | | $973.40 | $1,406.84 | $2,219.63 |
- 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
- $1,178.43 / $1,352.72 / $2,070.71
| Professional | | $1,178.43 | $1,352.72 | $2,070.71 |