- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,336.84 / $4,089.75 / $5,313.35
| Facility | | $3,336.84 | $4,089.75 | $5,313.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.64 / $164.64 / $529.04
| Professional | | $164.64 | $164.64 | $529.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.00 / $443.00 / $1,240.00
| Professional | | $369.00 | $443.00 | $1,240.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.33 / $396.36 / $1,587.42
| Professional | | $228.33 | $396.36 | $1,587.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.39 / $1,877.37 / $2,513.30
| Professional | | $1,040.39 | $1,877.37 | $2,513.30 |