- 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
- $827.67 / $834.31 / $1,148.08
| Professional | | $827.67 | $834.31 | $1,148.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.38 / $1,027.50 / $1,642.27
| Professional | | $873.38 | $1,027.50 | $1,642.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,204.36 / $1,720.43
| Professional | | $300.00 | $1,204.36 | $1,720.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $4,915.00 / $7,205.00
| Facility | | $1,649.00 | $4,915.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.96 / $1,042.84 / $1,716.96
| Professional | | $812.96 | $1,042.84 | $1,716.96 |