- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $4,073.80 / $5,011.87
| Facility | | $870.96 | $4,073.80 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $1,148.15 / $2,454.71
| Professional | | $245.47 | $1,148.15 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $3,235.94 / $7,079.46
| Professional | | $354.81 | $3,235.94 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $851.14 / $2,691.53
| Professional | | $316.23 | $851.14 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $3,235.94 / $3,467.37
| Professional | | $741.31 | $3,235.94 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $12,882.50 / $26,915.35
| Facility | | $3,311.31 | $12,882.50 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $1,000.00 / $3,715.35
| Professional | | $323.59 | $1,000.00 | $3,715.35 |