- 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
- $645.74 / $901.64 / $1,054.06
| Professional | | $645.74 | $901.64 | $1,054.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.72 / $849.43 / $1,214.31
| Professional | | $613.72 | $849.43 | $1,214.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.83 / $1,286.32 / $1,450.55
| Professional | | $884.83 | $1,286.32 | $1,450.55 |
- 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
- $640.84 / $1,017.81 / $1,549.26
| Professional | | $640.84 | $1,017.81 | $1,549.26 |