- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $5,496.04
| Facility | | $3,706.14 | $3,955.04 | $5,496.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.79 / $812.33 / $1,070.15
| Professional | | $797.79 | $812.33 | $1,070.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $845.01 / $994.13 / $1,547.59
| Professional | | $845.01 | $994.13 | $1,547.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,088.63 / $1,631.27
| Professional | | $300.00 | $1,088.63 | $1,631.27 |
- 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
- $794.56 / $1,130.75 / $1,880.52
| Professional | | $794.56 | $1,130.75 | $1,880.52 |