- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,726.50 / $3,418.74 / $3,921.60
| Facility | | $2,726.50 | $3,418.74 | $3,921.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.45 / $3,646.50 / $8,376.29
| Professional | | $280.45 | $3,646.50 | $8,376.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.00 / $922.00 / $1,426.00
| Professional | | $768.00 | $922.00 | $1,426.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.47 / $497.59 / $674.26
| Professional | | $300.47 | $497.59 | $674.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.63 / $523.52 / $1,157.64
| Professional | | $320.63 | $523.52 | $1,157.64 |