- 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
- $333.53 / $605.98 / $625.37
| Professional | | $333.53 | $605.98 | $625.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $534.40 / $628.71 / $1,043.55
| Professional | | $534.40 | $628.71 | $1,043.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $499.94 / $728.55 / $1,117.14
| Professional | | $499.94 | $728.55 | $1,117.14 |
- 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
- $534.63 / $705.53 / $1,088.76
| Professional | | $534.63 | $705.53 | $1,088.76 |