- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,981.07 / $9,772.37
| Facility | | $3,019.95 | $3,981.07 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,000.00 / $2,290.87
| Professional | | $691.83 | $1,000.00 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $794.33 / $1,318.26
| Professional | | $676.08 | $794.33 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,230.27 / $1,621.81
| Professional | | $870.96 | $1,230.27 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $15,135.61
| Facility | | $3,235.94 | $7,413.10 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $977.24 / $1,698.24
| Professional | | $676.08 | $977.24 | $1,698.24 |