- 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
- $848.78 / $875.59 / $1,154.10
| Professional | | $848.78 | $875.59 | $1,154.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.15 / $1,041.34 / $1,663.77
| Professional | | $885.15 | $1,041.34 | $1,663.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,135.76 / $1,773.33
| Professional | | $300.00 | $1,135.76 | $1,773.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $4,915.00 / $7,205.00
| Facility | | $1,649.00 | $4,915.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $862.39 / $1,143.48 / $1,445.02
| Professional | | $862.39 | $1,143.48 | $1,445.02 |