- 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
- $933.25 / $1,174.90 / $2,951.21
| Professional | | $933.25 | $1,174.90 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,000.00 / $1,659.59
| Professional | | $741.31 | $1,000.00 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $1,230.27 / $2,041.74
| Professional | | $208.93 | $1,230.27 | $2,041.74 |
- 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
- $870.96 / $1,230.27 / $1,905.46
| Professional | | $870.96 | $1,230.27 | $1,905.46 |