- 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
- $758.58 / $891.25 / $1,621.81
| Professional | | $758.58 | $891.25 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $1,621.81
| Professional | | $812.83 | $1,096.48 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $5,370.32
| Facility | | $831.76 | $831.76 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $1,258.93 / $1,949.84
| Professional | | $446.68 | $1,258.93 | $1,949.84 |
- 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
- $741.31 / $1,000.00 / $1,737.80
| Professional | | $741.31 | $1,000.00 | $1,737.80 |