- 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
- $481.40 / $863.86 / $968.30
| Professional | | $481.40 | $863.86 | $968.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.67 / $893.73 / $1,439.81
| Professional | | $759.67 | $893.73 | $1,439.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $714.41 / $1,035.67 / $1,577.21
| Professional | | $714.41 | $1,035.67 | $1,577.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $4,086.00 / $9,622.00
| Facility | | $3,146.00 | $4,086.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.09 / $1,063.65 / $1,630.98
| Professional | | $745.09 | $1,063.65 | $1,630.98 |