- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,383.00 / $4,736.00 / $6,907.00
| Facility | | $2,383.00 | $4,736.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.20 / $867.44 / $1,011.31
| Professional | | $707.20 | $867.44 | $1,011.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.86 / $1,026.34 / $1,451.87
| Professional | | $812.86 | $1,026.34 | $1,451.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,574.62 / $4,713.37 / $8,169.59
| Facility | | $3,574.62 | $4,713.37 | $8,169.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.54 / $907.81 / $1,002.45
| Professional | | $741.54 | $907.81 | $1,002.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.80 / $1,057.22 / $2,285.51
| Professional | | $818.80 | $1,057.22 | $2,285.51 |