- 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
- $582.13 / $806.94 / $903.52
| Professional | | $582.13 | $806.94 | $903.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.00 / $929.41 / $1,444.99
| Professional | | $790.00 | $929.41 | $1,444.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $1,032.43 / $1,581.72
| Professional | | $250.00 | $1,032.43 | $1,581.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.00 / $2,384.00 / $5,510.00
| Facility | | $1,395.00 | $2,384.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.05 / $1,096.39 / $1,694.69
| Professional | | $612.05 | $1,096.39 | $1,694.69 |