- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $3,981.07
| Facility | | $3,467.37 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,000.00 / $2,630.27
| Professional | | $707.95 | $1,000.00 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $954.99 / $1,548.82
| Professional | | $707.95 | $954.99 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,230.27 / $1,862.09
| Professional | | $181.97 | $1,230.27 | $1,862.09 |
- 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
- $660.69 / $1,122.02 / $1,949.84
| Professional | | $660.69 | $1,122.02 | $1,949.84 |