- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $645.65 / $1,513.56
| Professional | | $338.84 | $645.65 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,148.15 / $1,548.82
| Professional | | $724.44 | $1,148.15 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $776.25 / $1,288.25
| Professional | | $478.63 | $776.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,454.71 / $3,235.94
| Facility | | $794.33 | $2,454.71 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $812.83 / $1,698.24
| Professional | | $501.19 | $812.83 | $1,698.24 |