- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $741.31 / $2,041.74
| Professional | | $645.65 | $741.31 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $741.31 / $1,202.26
| Professional | | $630.96 | $741.31 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,288.25 / $1,513.56
| Professional | | $812.83 | $1,288.25 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $15,135.61
| Facility | | $3,715.35 | $7,762.47 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,000.00 / $1,584.89
| Professional | | $645.65 | $1,000.00 | $1,584.89 |