- 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
- $701.30 / $909.78 / $1,164.13
| Professional | | $701.30 | $909.78 | $1,164.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $694.37 / $961.06 / $1,547.30
| Professional | | $694.37 | $961.06 | $1,547.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.06 / $1,202.77 / $1,506.76
| Professional | | $961.06 | $1,202.77 | $1,506.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,080.00 / $3,912.00 / $7,350.00
| Facility | | $2,080.00 | $3,912.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $665.67 / $942.92 / $1,616.31
| Professional | | $665.67 | $942.92 | $1,616.31 |