- 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
- $856.96 / $863.65 / $1,180.85
| Professional | | $856.96 | $863.65 | $1,180.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.05 / $1,061.23 / $1,727.77
| Professional | | $902.05 | $1,061.23 | $1,727.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,280.44 / $1,783.56
| Professional | | $300.00 | $1,280.44 | $1,783.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $3,447.00 / $7,350.00
| Facility | | $2,569.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.28 / $1,111.93 / $1,775.37
| Professional | | $863.28 | $1,111.93 | $1,775.37 |