- 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
- $812.83 / $1,000.00 / $2,398.83
| Professional | | $812.83 | $1,000.00 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $870.96 / $1,445.44
| Professional | | $660.69 | $870.96 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,000.00 / $1,737.80
| Professional | | $181.97 | $1,000.00 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,122.02 / $1,698.24
| Professional | | $758.58 | $1,122.02 | $1,698.24 |