- 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
- $602.84 / $876.67 / $983.93
| Professional | | $602.84 | $876.67 | $983.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.50 / $1,050.00 / $1,490.86
| Professional | | $892.50 | $1,050.00 | $1,490.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $652.95 / $1,051.03 / $1,884.40
| Professional | | $652.95 | $1,051.03 | $1,884.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $4,628.00 / $7,350.00
| Facility | | $2,654.00 | $4,628.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $716.40 / $906.21 / $1,370.54
| Professional | | $716.40 | $906.21 | $1,370.54 |