- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $10,715.19
| Facility | | $3,890.45 | $3,890.45 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,148.15 / $1,548.82
| Professional | | $831.76 | $1,148.15 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,951.21 / $8,912.51
| Facility | | $2,630.27 | $2,951.21 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $1,000.00 / $1,445.44
| Professional | | $512.86 | $1,000.00 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,786.30 / $6,760.83
| Facility | | $2,511.89 | $4,786.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $2,951.21
| Professional | | $1,548.82 | $1,548.82 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $1,548.82
| Professional | | $912.01 | $912.01 | $1,548.82 |