- 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
- $520.66 / $919.51 / $1,045.14
| Professional | | $520.66 | $919.51 | $1,045.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $807.00 / $949.41 / $1,571.25
| Professional | | $807.00 | $949.41 | $1,571.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.85 / $1,178.98 / $2,292.55
| Professional | | $626.85 | $1,178.98 | $2,292.55 |
- 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
- $773.40 / $1,055.06 / $1,636.36
| Professional | | $773.40 | $1,055.06 | $1,636.36 |