- 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
- $831.76 / $1,000.00 / $2,511.89
| Professional | | $831.76 | $1,000.00 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,258.93 / $1,778.28
| Professional | | $933.25 | $1,258.93 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $5,370.32 / $5,370.32
| Facility | | $954.99 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $1,380.38 / $2,238.72
| Professional | | $537.03 | $1,380.38 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $6,025.60 / $12,589.25
| Facility | | $1,230.27 | $6,025.60 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,122.02 / $2,041.74
| Professional | | $812.83 | $1,122.02 | $2,041.74 |