- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,819.70 / $3,890.45
| Facility | | $933.25 | $1,819.70 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,000.00 / $1,148.15
| Professional | | $707.95 | $1,000.00 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,884.03 / $4,897.79
| Facility | | $2,691.53 | $2,884.03 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $21.38 / $25.12
| Professional | | $21.38 | $21.38 | $25.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $9,332.54 / $22,908.68
| Facility | | $1,348.96 | $9,332.54 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,380.38 / $2,818.38
| Professional | | $1,023.29 | $1,380.38 | $2,818.38 |