- 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
- $317.70 / $649.27 / $947.64
| Professional | | $317.70 | $649.27 | $947.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.70 / $986.70 / $1,115.69
| Professional | | $838.70 | $986.70 | $1,115.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.69 / $1,189.20 / $1,726.63
| Professional | | $642.69 | $1,189.20 | $1,726.63 |
- 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
- $517.41 / $814.05 / $1,705.94
| Professional | | $517.41 | $814.05 | $1,705.94 |