- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $3,981.07
| Facility | | $3,019.95 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $676.08 / $1,412.54
| Professional | | $446.68 | $676.08 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $549.54 / $1,000.00
| Professional | | $416.87 | $549.54 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $758.58 / $1,318.26
| Professional | | $251.19 | $758.58 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $691.83 / $1,174.90
| Professional | | $501.19 | $691.83 | $1,174.90 |