- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.26 / $3,706.14 / $4,026.21
| Facility | | $3,438.26 | $3,706.14 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $706.76 / $960.28 / $1,280.27
| Professional | | $706.76 | $960.28 | $1,280.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.49 / $911.40 / $1,500.00
| Professional | | $658.49 | $911.40 | $1,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $939.30 / $1,326.14 / $1,604.09
| Professional | | $939.30 | $1,326.14 | $1,604.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $535.97 / $1,061.58 / $1,641.35
| Professional | | $535.97 | $1,061.58 | $1,641.35 |