- 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
- $750.94 / $830.75 / $974.47
| Professional | | $750.94 | $830.75 | $974.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.79 / $920.93 / $1,454.75
| Professional | | $782.79 | $920.93 | $1,454.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,005.05 / $1,554.40
| Professional | | $300.00 | $1,005.05 | $1,554.40 |
- 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
- $678.70 / $1,064.88 / $1,620.44
| Professional | | $678.70 | $1,064.88 | $1,620.44 |