- 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
- $630.96 / $724.44 / $1,995.26
| Professional | | $630.96 | $724.44 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $724.44 / $1,174.90
| Professional | | $630.96 | $724.44 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,258.93 / $1,479.11
| Professional | | $794.33 | $1,258.93 | $1,479.11 |
- 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 / $1,548.82
| Professional | | $645.65 | $1,000.00 | $1,548.82 |