- 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
- $575.44 / $691.83 / $1,621.81
| Professional | | $575.44 | $691.83 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $616.60 / $1,000.00
| Professional | | $467.74 | $616.60 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $707.95 / $1,230.27
| Professional | | $89.13 | $707.95 | $1,230.27 |
- 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
- $537.03 / $776.25 / $1,202.26
| Professional | | $537.03 | $776.25 | $1,202.26 |