- 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
- $650.45 / $1,017.80 / $1,140.33
| Professional | | $650.45 | $1,017.80 | $1,140.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.28 / $646.21 / $646.21
| Professional | | $549.28 | $646.21 | $646.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.32 / $1,278.02 / $2,778.36
| Professional | | $518.32 | $1,278.02 | $2,778.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $351.71 / $453.38 / $929.36
| Professional | | $351.71 | $453.38 | $929.36 |