- 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
- $786.29 / $802.16 / $1,061.76
| Professional | | $786.29 | $802.16 | $1,061.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.65 / $964.29 / $1,522.18
| Professional | | $819.65 | $964.29 | $1,522.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,051.78 / $1,615.03
| Professional | | $300.00 | $1,051.78 | $1,615.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $3,447.00 / $7,350.00
| Facility | | $2,654.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $793.56 / $1,116.73 / $1,536.22
| Professional | | $793.56 | $1,116.73 | $1,536.22 |