- 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
- $814.74 / $821.50 / $1,134.96
| Professional | | $814.74 | $821.50 | $1,134.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.72 / $1,011.44 / $1,617.96
| Professional | | $859.72 | $1,011.44 | $1,617.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,225.25 / $1,696.04
| Professional | | $300.00 | $1,225.25 | $1,696.04 |
- 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
- $820.42 / $1,175.64 / $1,690.89
| Professional | | $820.42 | $1,175.64 | $1,690.89 |