- 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
- $389.09 / $704.10 / $712.38
| Professional | | $389.09 | $704.10 | $712.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $632.64 / $744.28 / $1,088.79
| Professional | | $632.64 | $744.28 | $1,088.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $569.14 / $865.81 / $1,319.33
| Professional | | $569.14 | $865.81 | $1,319.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $4,915.00 / $7,205.00
| Facility | | $1,649.00 | $4,915.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.83 / $832.58 / $1,286.61
| Professional | | $608.83 | $832.58 | $1,286.61 |