- 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
- $335.11 / $617.97 / $674.49
| Professional | | $335.11 | $617.97 | $674.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $544.50 / $640.59 / $1,003.21
| Professional | | $544.50 | $640.59 | $1,003.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $509.66 / $741.69 / $1,137.83
| Professional | | $509.66 | $741.69 | $1,137.83 |
- 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
- $543.05 / $733.03 / $1,123.43
| Professional | | $543.05 | $733.03 | $1,123.43 |