- 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
- $502.88 / $945.68 / $953.72
| Professional | | $502.88 | $945.68 | $953.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.22 / $990.85 / $1,412.61
| Professional | | $842.22 | $990.85 | $1,412.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $788.36 / $1,147.86 / $1,758.08
| Professional | | $788.36 | $1,147.86 | $1,758.08 |
- 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
- $814.18 / $1,111.42 / $1,702.51
| Professional | | $814.18 | $1,111.42 | $1,702.51 |