- 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
- $629.23 / $833.92 / $995.83
| Professional | | $629.23 | $833.92 | $995.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.16 / $861.12 / $1,172.83
| Professional | | $622.16 | $861.12 | $1,172.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.00 / $1,070.86 / $1,440.91
| Professional | | $897.00 | $1,070.86 | $1,440.91 |
- 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
- $604.74 / $1,018.52 / $1,540.35
| Professional | | $604.74 | $1,018.52 | $1,540.35 |