- 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
- $912.01 / $1,202.26 / $3,019.95
| Professional | | $912.01 | $1,202.26 | $3,019.95 |
- 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 / $1,258.93 / $1,995.26
| Professional | | $208.93 | $1,258.93 | $1,995.26 |
- 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 / $1,202.26 / $1,862.09
| Professional | | $870.96 | $1,202.26 | $1,862.09 |