- 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
- $889.20 / $907.44 / $1,186.24
| Professional | | $889.20 | $907.44 | $1,186.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.79 / $1,117.40 / $1,706.08
| Professional | | $949.79 | $1,117.40 | $1,706.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,334.18 / $1,877.70
| Professional | | $300.00 | $1,334.18 | $1,877.70 |
- 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
- $901.59 / $1,306.78 / $1,865.70
| Professional | | $901.59 | $1,306.78 | $1,865.70 |