- 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
- $475.53 / $723.73 / $1,146.03
| Professional | | $475.53 | $723.73 | $1,146.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.59 / $701.65 / $1,309.20
| Professional | | $494.59 | $701.65 | $1,309.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.67 / $1,033.33 / $1,401.07
| Professional | | $638.67 | $1,033.33 | $1,401.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $614.24 / $1,000.09 / $1,593.60
| Professional | | $614.24 | $1,000.09 | $1,593.60 |