- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,861.66 / $2,861.66 / $16,868.75
| Facility | | $2,861.66 | $2,861.66 | $16,868.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $669.25 / $669.25 / $2,822.41
| Professional | | $669.25 | $669.25 | $2,822.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.00 / $1,683.00 / $2,020.00
| Professional | | $1,492.00 | $1,683.00 | $2,020.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.16 / $953.21 / $1,581.64
| Professional | | $940.16 | $953.21 | $1,581.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.90 / $1,763.75 / $2,797.09
| Professional | | $1,065.90 | $1,763.75 | $2,797.09 |