- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,235.94 / $7,585.78
| Facility | | $2,187.76 | $3,235.94 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,570.40 / $3,801.89
| Professional | | $1,621.81 | $2,570.40 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,090.30 / $6,025.60
| Facility | | $2,454.71 | $3,090.30 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,187.76 / $3,467.37
| Professional | | $1,513.56 | $2,187.76 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Professional | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,000.00 / $1,659.59
| Professional | | $851.14 | $1,000.00 | $1,659.59 |