- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $3,981.07
| Facility | | $3,467.37 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,000.00 / $1,380.38
| Professional | | $660.69 | $1,000.00 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $549.54 / $776.25
| Professional | | $457.09 | $549.54 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $18,620.87
| Facility | | $3,715.35 | $7,762.47 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $954.99 / $1,698.24
| Professional | | $549.54 | $954.99 | $1,698.24 |