- 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
- $581.25 / $823.63 / $1,035.15
| Professional | | $581.25 | $823.63 | $1,035.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.17 / $668.75 / $1,301.89
| Professional | | $483.17 | $668.75 | $1,301.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $696.62 / $1,120.89 / $1,354.18
| Professional | | $696.62 | $1,120.89 | $1,354.18 |
- 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
- $582.70 / $933.11 / $1,443.89
| Professional | | $582.70 | $933.11 | $1,443.89 |