- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,073.80
| Facility | | $3,981.07 | $3,981.07 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,000.00 / $2,398.83
| Professional | | $758.58 | $1,000.00 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $794.33 / $1,380.38
| Professional | | $588.84 | $794.33 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,023.29 / $1,621.81
| Professional | | $181.97 | $1,023.29 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $13,489.63
| Facility | | $3,715.35 | $7,762.47 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $977.24 / $1,659.59
| Professional | | $691.83 | $977.24 | $1,659.59 |