- 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
- $743.58 / $791.85 / $1,020.28
| Professional | | $743.58 | $791.85 | $1,020.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.88 / $978.68 / $1,424.69
| Professional | | $831.88 | $978.68 | $1,424.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $1,069.98 / $1,619.39
| Professional | | $200.00 | $1,069.98 | $1,619.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $4,086.00 / $9,622.00
| Facility | | $3,146.00 | $4,086.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.04 / $960.46 / $1,533.10
| Professional | | $748.04 | $960.46 | $1,533.10 |