- 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
- $776.13 / $807.94 / $1,076.91
| Professional | | $776.13 | $807.94 | $1,076.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.29 / $952.10 / $1,551.32
| Professional | | $809.29 | $952.10 | $1,551.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,038.63 / $1,644.90
| Professional | | $300.00 | $1,038.63 | $1,644.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $4,086.00 / $9,622.00
| Facility | | $3,146.00 | $4,086.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.92 / $1,106.34 / $1,516.97
| Professional | | $801.92 | $1,106.34 | $1,516.97 |