- 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
- $909.55 / $929.25 / $1,242.58
| Professional | | $909.55 | $929.25 | $1,242.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.80 / $1,112.70 / $1,767.54
| Professional | | $945.80 | $1,112.70 | $1,767.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,211.31 / $1,866.97
| Professional | | $300.00 | $1,211.31 | $1,866.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $4,915.00 / $7,205.00
| Facility | | $1,649.00 | $4,915.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.16 / $1,130.36 / $1,760.87
| Professional | | $928.16 | $1,130.36 | $1,760.87 |