- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $3,981.07
| Facility | | $2,089.30 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $831.76 / $2,089.30
| Professional | | $616.60 | $831.76 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $812.83 / $1,380.38
| Professional | | $602.56 | $812.83 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,174.90 / $1,698.24
| Professional | | $741.31 | $1,174.90 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,000.00 / $1,698.24
| Professional | | $630.96 | $1,000.00 | $1,698.24 |