- 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
- $537.03 / $812.83 / $2,089.30
| Professional | | $537.03 | $812.83 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $707.95 / $1,230.27
| Professional | | $537.03 | $707.95 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $1,047.13 / $1,513.56
| Professional | | $446.68 | $1,047.13 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- 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 |