- 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
- $404.95 / $802.01 / $805.11
| Professional | | $404.95 | $802.01 | $805.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $629.55 / $740.66 / $1,198.33
| Professional | | $629.55 | $740.66 | $1,198.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.78 / $859.67 / $1,491.23
| Professional | | $661.78 | $859.67 | $1,491.23 |
- 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
- $622.46 / $914.16 / $1,458.30
| Professional | | $622.46 | $914.16 | $1,458.30 |