- 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
- $460.16 / $631.13 / $788.52
| Professional | | $460.16 | $631.13 | $788.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $463.39 / $641.36 / $1,071.90
| Professional | | $463.39 | $641.36 | $1,071.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.37 / $832.77 / $1,062.45
| Professional | | $641.37 | $832.77 | $1,062.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $458.49 / $628.57 / $1,137.32
| Professional | | $458.49 | $628.57 | $1,137.32 |