- 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
- $567.22 / $704.29 / $919.51
| Professional | | $567.22 | $704.29 | $919.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.41 / $789.51 / $1,195.44
| Professional | | $570.41 | $789.51 | $1,195.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $789.52 / $936.19 / $1,310.73
| Professional | | $789.52 | $936.19 | $1,310.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.23 / $886.43 / $1,436.24
| Professional | | $571.23 | $886.43 | $1,436.24 |