- 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
- $988.66 / $1,394.68 / $1,417.51
| Professional | | $988.66 | $1,394.68 | $1,417.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.08 / $1,489.50 / $2,451.69
| Professional | | $1,266.08 | $1,489.50 | $2,451.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,710.78 / $2,688.69
| Professional | | $300.00 | $1,710.78 | $2,688.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $3,447.00 / $7,350.00
| Facility | | $2,654.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.30 / $1,798.87 / $2,777.94
| Professional | | $988.30 | $1,798.87 | $2,777.94 |