- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.72 / $829.12 / $1,151.21
| Professional | | $822.72 | $829.12 | $1,151.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $867.48 / $1,020.56 / $1,632.62
| Professional | | $867.48 | $1,020.56 | $1,632.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $1,226.67 / $1,709.70
| Professional | | $350.00 | $1,226.67 | $1,709.70 |
- 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
- $823.58 / $1,185.10 / $1,705.94
| Professional | | $823.58 | $1,185.10 | $1,705.94 |