- 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
- $335.20 / $440.82 / $583.94
| Professional | | $335.20 | $440.82 | $583.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $333.02 / $508.84 / $741.89
| Professional | | $333.02 | $508.84 | $741.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.71 / $559.16 / $1,034.59
| Professional | | $386.71 | $559.16 | $1,034.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.00 / $2,445.00 / $4,602.00
| Facility | | $1,388.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.80 / $648.91 / $1,146.15
| Professional | | $363.80 | $648.91 | $1,146.15 |