- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,305.36 / $1,501.18 / $2,610.73
| Facility | | $1,305.36 | $1,501.18 | $2,610.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.19 / $1,109.56 / $1,266.21
| Professional | | $1,018.19 | $1,109.56 | $1,266.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.67 / $69.98 / $94.15
| Facility | | $57.67 | $69.98 | $94.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $846.99
| Professional | | $100.00 | $100.00 | $846.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $848.49 / $1,060.60 / $2,825.47
| Facility | | $848.49 | $1,060.60 | $2,825.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $548.26 / $548.26 / $1,305.36
| Professional | | $548.26 | $548.26 | $1,305.36 |