- 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
- $320.33 / $581.01 / $600.47
| Professional | | $320.33 | $581.01 | $600.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.42 / $604.03 / $843.06
| Professional | | $513.42 | $604.03 | $843.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.65 / $699.97 / $1,071.26
| Professional | | $481.65 | $699.97 | $1,071.26 |
- 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
- $513.37 / $678.70 / $1,044.02
| Professional | | $513.37 | $678.70 | $1,044.02 |