- 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
- $909.62 / $919.60 / $1,261.54
| Professional | | $909.62 | $919.60 | $1,261.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.65 / $1,120.76 / $1,826.81
| Professional | | $952.65 | $1,120.76 | $1,826.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,362.16 / $1,954.69
| Professional | | $300.00 | $1,362.16 | $1,954.69 |
- 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
- $808.62 / $1,305.09 / $1,870.61
| Professional | | $808.62 | $1,305.09 | $1,870.61 |