- 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
- $742.43 / $752.75 / $1,042.51
| Professional | | $742.43 | $752.75 | $1,042.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $807.76 / $950.31 / $1,444.11
| Professional | | $807.76 | $950.31 | $1,444.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,084.74 / $1,563.91
| Professional | | $300.00 | $1,084.74 | $1,563.91 |
- 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
- $761.39 / $1,084.04 / $1,564.26
| Professional | | $761.39 | $1,084.04 | $1,564.26 |