- 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
- $891.25 / $1,000.00 / $2,754.23
| Professional | | $891.25 | $1,000.00 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,000.00 / $1,659.59
| Professional | | $891.25 | $1,000.00 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,479.11 / $2,041.74
| Professional | | $1,122.02 | $1,479.11 | $2,041.74 |
- 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
- $851.14 / $1,202.26 / $2,187.76
| Professional | | $851.14 | $1,202.26 | $2,187.76 |