- 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
- $358.85 / $631.66 / $670.05
| Professional | | $358.85 | $631.66 | $670.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $556.32 / $654.49 / $1,160.25
| Professional | | $556.32 | $654.49 | $1,160.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.33 / $758.42 / $1,163.72
| Professional | | $520.33 | $758.42 | $1,163.72 |
- 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
- $573.52 / $734.12 / $1,134.25
| Professional | | $573.52 | $734.12 | $1,134.25 |