- 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
- $674.13 / $941.88 / $1,080.69
| Professional | | $674.13 | $941.88 | $1,080.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.50 / $886.50 / $1,402.64
| Professional | | $640.50 | $886.50 | $1,402.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.44 / $1,159.94 / $1,514.80
| Professional | | $923.44 | $1,159.94 | $1,514.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.76 / $1,050.01 / $1,591.12
| Professional | | $635.76 | $1,050.01 | $1,591.12 |