- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $5,496.04
| Facility | | $3,706.14 | $3,955.04 | $5,496.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.20 / $839.32 / $1,210.00
| Professional | | $583.20 | $839.32 | $1,210.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.76 / $819.64 / $1,499.19
| Professional | | $654.76 | $819.64 | $1,499.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $853.83 / $1,065.98 / $1,608.56
| Professional | | $853.83 | $1,065.98 | $1,608.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $677.30 / $1,115.00 / $1,700.66
| Professional | | $677.30 | $1,115.00 | $1,700.66 |