- 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
- $961.67 / $1,343.59 / $1,450.42
| Professional | | $961.67 | $1,343.59 | $1,450.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.41 / $1,531.07 / $2,376.67
| Professional | | $1,301.41 | $1,531.07 | $2,376.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,662.85 / $2,608.41
| Professional | | $300.00 | $1,662.85 | $2,608.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,599.00 / $7,228.00 / $12,680.00
| Facility | | $3,599.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.05 / $1,808.06 / $2,648.33
| Professional | | $1,086.05 | $1,808.06 | $2,648.33 |