- 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
- $707.95 / $1,000.00 / $2,454.71
| Professional | | $707.95 | $1,000.00 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $891.25 / $1,584.89
| Professional | | $676.08 | $891.25 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,122.02 / $1,905.46
| Professional | | $181.97 | $1,122.02 | $1,905.46 |
- 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
- $741.31 / $1,122.02 / $1,819.70
| Professional | | $741.31 | $1,122.02 | $1,819.70 |