- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,489.63 / $4,013.07 / $6,979.26
| Facility | | $3,489.63 | $4,013.07 | $6,979.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.91 / $2,966.19 / $3,384.94
| Professional | | $2,721.91 | $2,966.19 | $3,384.94 |
- 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
- $321.10 / $390.00 / $2,264.25
| Professional | | $321.10 | $390.00 | $2,264.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,268.26 / $2,835.33 / $7,553.31
| Facility | | $2,268.26 | $2,835.33 | $7,553.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.64 / $1,465.64 / $2,093.78
| Professional | | $1,465.64 | $1,465.64 | $2,093.78 |