- 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
- $870.96 / $1,000.00 / $2,570.40
| Professional | | $870.96 | $1,000.00 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $977.24 / $1,659.59
| Professional | | $870.96 | $977.24 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,380.38 / $1,995.26
| Professional | | $1,096.48 | $1,380.38 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $7,762.47 / $19,054.61
| Facility | | $4,466.84 | $7,762.47 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,174.90 / $2,137.96
| Professional | | $831.76 | $1,174.90 | $2,137.96 |