- 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
- $809.17 / $816.64 / $1,122.68
| Professional | | $809.17 | $816.64 | $1,122.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $854.56 / $1,005.36 / $1,606.39
| Professional | | $854.56 | $1,005.36 | $1,606.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,169.59 / $1,684.69
| Professional | | $300.00 | $1,169.59 | $1,684.69 |
- 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
- $744.28 / $1,167.77 / $1,680.64
| Professional | | $744.28 | $1,167.77 | $1,680.64 |